- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $144.54 / $281.84
| Professional | | $109.65 | $144.54 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.86 / $75.86 / $75.86
| Facility | | $75.86 | $75.86 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $147.91 / $257.04
| Professional | | $97.72 | $147.91 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $933.25
| Professional | | $933.25 | $933.25 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $144.54 / $501.19
| Facility | | $144.54 | $144.54 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $141.25 / $234.42
| Professional | | $104.71 | $141.25 | $234.42 |