- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.74 / $318.64 / $398.31
| Professional | | $173.74 | $318.64 | $398.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $205.00 / $1,300.00
| Facility | | $55.00 | $205.00 | $1,300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.43 / $504.55 / $1,157.05
| Professional | | $144.43 | $504.55 | $1,157.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.06 / $205.00 / $205.00
| Facility | | $153.06 | $205.00 | $205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.21 / $205.00 / $258.52
| Professional | | $139.21 | $205.00 | $258.52 |