- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.68 / $203.68 / $203.68
| Facility | | $203.68 | $203.68 | $203.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $203.68
| Professional | | $150.00 | $150.00 | $203.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.77 / $309.50 / $317.20
| Professional | | $261.77 | $309.50 | $317.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.13 / $252.63 / $317.66
| Professional | | $250.13 | $252.63 | $317.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.06 / $203.68 / $1,100.50
| Facility | | $117.06 | $203.68 | $1,100.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.75 / $116.30 / $223.07
| Professional | | $89.75 | $116.30 | $223.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.84 / $111.54 / $223.07
| Professional | | $69.84 | $111.54 | $223.07 |