- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.48 / $593.82 / $835.99
| Professional | | $109.48 | $593.82 | $835.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.09 / $175.09 / $175.09
| Facility | | $175.09 | $175.09 | $175.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.83 / $192.64 / $261.89
| Professional | | $148.83 | $192.64 | $261.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $99.06 / $157.29 / $271.05
| Facility | | $99.06 | $157.29 | $271.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.83 / $209.36 / $299.94
| Professional | | $148.83 | $209.36 | $299.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.92 / $267.87 / $290.57
| Professional | | $236.92 | $267.87 | $290.57 |