- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.60 / $138.97 / $289.85
| Professional | | $115.60 | $138.97 | $289.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.59 / $503.59 / $503.59
| Professional | | $503.59 | $503.59 | $503.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.42 / $175.62 / $175.62
| Professional | | $119.42 | $175.62 | $175.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.15 / $167.70 / $229.53
| Professional | | $128.15 | $167.70 | $229.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.15 / $190.91 / $190.91
| Facility | | $0.15 | $190.91 | $190.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.61 / $156.03 / $204.45
| Professional | | $127.61 | $156.03 | $204.45 |