- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.95 / $117.82 / $795.26
| Professional | | $95.95 | $117.82 | $795.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $207.00 / $207.00 / $207.00
| Facility | | $207.00 | $207.00 | $207.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.96 / $254.61 / $308.94
| Professional | | $231.96 | $254.61 | $308.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $207.00 / $207.00 / $207.00
| Facility | | $207.00 | $207.00 | $207.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.25 / $254.61 / $308.94
| Professional | | $99.25 | $254.61 | $308.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.02 / $168.73 / $556.55
| Professional | | $54.02 | $168.73 | $556.55 |