- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.40 / $130.50 / $204.51
| Professional | | $104.40 | $130.50 | $204.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $217.78 / $217.78
| Professional | | $150.00 | $217.78 | $217.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $84.42 / $114.80 / $207.12
| Facility | | $84.42 | $114.80 | $207.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.20 / $322.00 / $491.77
| Professional | | $101.20 | $322.00 | $491.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.00 / $156.00 / $156.00
| Facility | | $156.00 | $156.00 | $156.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.20 / $143.00 / $158.00
| Professional | | $101.20 | $143.00 | $158.00 |