- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.64 / $252.64 / $252.64
| Professional | | $252.64 | $252.64 | $252.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.94 / $31.94 / $31.94
| Facility | | $31.94 | $31.94 | $31.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.94 / $31.94 / $31.94
| Professional | | $31.94 | $31.94 | $31.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.13 / $140.13 / $196.20
| Facility | | $140.13 | $140.13 | $196.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.33 / $161.16 / $215.82
| Professional | | $145.33 | $161.16 | $215.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $3,000.00
| Professional | | $45.00 | $45.00 | $3,000.00 |