- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.48 / $182.10 / $206.86
| Professional | | $165.48 | $182.10 | $206.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.00 / $95.00 / $95.00
| Facility | | $95.00 | $95.00 | $95.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.00 / $200.87 / $500.00
| Professional | | $86.00 | $200.87 | $500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.00 / $149.46 / $189.94
| Facility | | $95.00 | $149.46 | $189.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.00 / $139.55 / $200.87
| Professional | | $90.00 | $139.55 | $200.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.09 / $168.60 / $238.40
| Professional | | $77.09 | $168.60 | $238.40 |