- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.86 / $160.06 / $205.20
| Professional | | $137.86 | $160.06 | $205.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.98 / $235.98 / $235.98
| Professional | | $235.98 | $235.98 | $235.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.87 / $87.87 / $87.87
| Professional | | $87.87 | $87.87 | $87.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.47 / $171.26 / $258.00
| Facility | | $147.47 | $171.26 | $258.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.51 / $107.56 / $1,182.56
| Professional | | $71.51 | $107.56 | $1,182.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.88 / $97.22 / $137.72
| Professional | | $60.88 | $97.22 | $137.72 |