- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.67 / $107.06 / $133.82
| Professional | | $84.67 | $107.06 | $133.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $156.81
| Professional | | $150.00 | $150.00 | $156.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.95 / $71.81 / $204.03
| Facility | | $64.95 | $71.81 | $204.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.46 / $95.00 / $108.00
| Professional | | $52.46 | $95.00 | $108.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.46 / $52.46 / $108.00
| Facility | | $52.46 | $52.46 | $108.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.77 / $95.00 / $108.00
| Professional | | $64.77 | $95.00 | $108.00 |