- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.75 / $131.52 / $164.40
| Professional | | $76.75 | $131.52 | $164.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.77 / $153.77 / $153.77
| Facility | | $153.77 | $153.77 | $153.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.44 / $153.77 / $288.75
| Professional | | $18.44 | $153.77 | $288.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17.14 / $100.00 / $1,123.95
| Facility | | $17.14 | $100.00 | $1,123.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.30 / $105.46 / $170.63
| Professional | | $70.30 | $105.46 | $170.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.65 / $105.37 / $170.63
| Professional | | $77.65 | $105.37 | $170.63 |