- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.97 / $132.97 / $164.28
| Professional | | $132.97 | $132.97 | $164.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.03 / $34.03 / $34.03
| Professional | | $34.03 | $34.03 | $34.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $178.86 / $178.86 / $178.86
| Facility | | $178.86 | $178.86 | $178.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.14 / $178.86 / $417.24
| Professional | | $20.14 | $178.86 | $417.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.64 / $132.97 / $303.52
| Facility | | $23.64 | $132.97 | $303.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.14 / $178.86 / $417.24
| Professional | | $20.14 | $178.86 | $417.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.44 / $110.44 / $184.06
| Professional | | $110.44 | $110.44 | $184.06 |