- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.50 / $127.50 / $208.59
| Professional | | $127.50 | $127.50 | $208.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.00 / $321.00 / $539.00
| Professional | | $220.00 | $321.00 | $539.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.20 / $255.36 / $458.05
| Professional | | $165.20 | $255.36 | $458.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.95 / $490.53 / $776.16
| Professional | | $290.95 | $490.53 | $776.16 |