- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.88 / $193.53 / $998.99
| Professional | | $150.88 | $193.53 | $998.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $311.80 / $311.80 / $311.80
| Facility | | $311.80 | $311.80 | $311.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.07 / $297.27 / $504.85
| Professional | | $192.07 | $297.27 | $504.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.54 / $252.95 / $354.83
| Facility | | $192.54 | $252.95 | $354.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.15 / $311.80 / $513.04
| Professional | | $193.15 | $311.80 | $513.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.50 / $313.19 / $389.76
| Professional | | $254.50 | $313.19 | $389.76 |