- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.41 / $103.96 / $701.71
| Professional | | $69.41 | $103.96 | $701.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.64 / $182.64 / $182.64
| Facility | | $182.64 | $182.64 | $182.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.38 / $224.88 / $272.45
| Professional | | $204.38 | $224.88 | $272.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.64 / $182.64 / $182.64
| Facility | | $182.64 | $182.64 | $182.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.57 / $224.88 / $272.45
| Professional | | $87.57 | $224.88 | $272.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.67 / $152.78 / $252.13
| Professional | | $47.67 | $152.78 | $252.13 |