- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.90 / $133.50 / $153.62
| Professional | | $122.90 | $133.50 | $153.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.00 / $101.00 / $101.00
| Facility | | $101.00 | $101.00 | $101.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.00 / $146.47 / $500.00
| Professional | | $86.00 | $146.47 | $500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $86.94 / $109.19 / $139.58
| Facility | | $86.94 | $109.19 | $139.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.00 / $109.19 / $146.47
| Professional | | $86.00 | $109.19 | $146.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.20 / $124.50 / $176.60
| Professional | | $75.20 | $124.50 | $176.60 |