- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $308.76 / $411.68
| Professional | | $190.55 | $308.76 | $411.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.53 / $42.53 / $42.53
| Professional | | $42.53 | $42.53 | $42.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $327.62 / $327.62 / $342.27
| Facility | | $327.62 | $327.62 | $342.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.42 / $327.62 / $551.25
| Professional | | $42.42 | $327.62 | $551.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.75 / $100.00 / $200.00
| Professional | | $57.75 | $100.00 | $200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.35 / $77.79 / $496.09
| Professional | | $58.35 | $77.79 | $496.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.06 / $306.43 / $471.63
| Professional | | $203.06 | $306.43 | $471.63 |