- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.03 / $173.78 / $217.22
| Professional | | $149.03 | $173.78 | $217.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.00 / $184.25 / $237.78
| Facility | | $105.00 | $184.25 | $237.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.00 / $215.22 / $541.32
| Professional | | $67.00 | $215.22 | $541.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.36 / $105.00 / $114.75
| Facility | | $91.36 | $105.00 | $114.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.00 / $114.75 / $159.90
| Professional | | $74.00 | $114.75 | $159.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.50 / $164.40 / $224.80
| Professional | | $61.50 | $164.40 | $224.80 |