- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.93 / $143.93 / $143.93
| Professional | | $143.93 | $143.93 | $143.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $58.40 / $85.00
| Professional | | $50.00 | $58.40 | $85.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,900.00 / $5,900.00 / $5,900.00
| Professional | | $5,900.00 | $5,900.00 | $5,900.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $65.00 / $65.00 / $100.00
| Facility | | $65.00 | $65.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.93 / $143.93 / $143.93
| Professional | | $143.93 | $143.93 | $143.93 |