- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.72 / $831.59 / $831.59
| Professional | | $148.72 | $831.59 | $831.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $187.53 / $252.19 / $382.17
| Facility | | $187.53 | $252.19 | $382.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.48 / $185.85 / $187.53
| Professional | | $48.48 | $185.85 | $187.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.98 / $219.86 / $382.17
| Facility | | $113.98 | $219.86 | $382.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.40 / $116.40 / $187.53
| Professional | | $116.40 | $116.40 | $187.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.90 / $54.32 / $221.43
| Professional | | $44.90 | $54.32 | $221.43 |