- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.32 / $157.90 / $260.41
| Professional | | $126.32 | $157.90 | $260.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $150.00 / $220.41
| Professional | | $100.00 | $150.00 | $220.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $71.84 / $116.60
| Facility | | $55.00 | $71.84 | $116.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.00 / $318.20 / $318.20
| Professional | | $55.00 | $318.20 | $318.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $55.00
| Facility | | $55.00 | $55.00 | $55.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $55.00 / $97.24
| Professional | | $50.00 | $55.00 | $97.24 |