- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.78 / $123.91 / $589.38
| Professional | | $102.78 | $123.91 | $589.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.67 / $176.67 / $176.67
| Facility | | $176.67 | $176.67 | $176.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.02 / $176.67 / $326.29
| Professional | | $114.02 | $176.67 | $326.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.50 / $167.87 / $249.84
| Facility | | $104.50 | $167.87 | $249.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.47 / $182.25 / $303.69
| Professional | | $118.47 | $182.25 | $303.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.13 / $202.20 / $260.64
| Professional | | $165.13 | $202.20 | $260.64 |