- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.90 / $201.96 / $252.45
| Professional | | $119.90 | $201.96 | $252.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.50 / $240.50 / $324.72
| Facility | | $240.50 | $240.50 | $324.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.88 / $240.50 / $386.25
| Professional | | $26.88 | $240.50 | $386.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.32 / $150.28 / $1,757.61
| Facility | | $26.32 | $150.28 | $1,757.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.86 / $164.78 / $288.32
| Professional | | $109.86 | $164.78 | $288.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.26 / $164.78 / $288.32
| Professional | | $121.26 | $164.78 | $288.32 |