- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.80 / $226.20 / $272.36
| Professional | | $188.80 | $226.20 | $272.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.00 / $46.00 / $71.00
| Professional | | $25.00 | $46.00 | $71.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.10 / $56.10 / $62.50
| Professional | | $56.10 | $56.10 | $62.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.44 / $185.61 / $253.72
| Facility | | $109.44 | $185.61 | $253.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $483.00 / $483.00 / $483.00
| Professional | | $483.00 | $483.00 | $483.00 |