- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.08 / $306.05 / $397.74
| Professional | | $277.08 | $306.05 | $397.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.84 / $53.84 / $53.84
| Facility | | $53.84 | $53.84 | $53.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.86 / $39.86 / $39.86
| Professional | | $39.86 | $39.86 | $39.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.77 / $172.77 / $497.95
| Facility | | $172.77 | $172.77 | $497.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.07 / $172.77 / $172.77
| Professional | | $36.07 | $172.77 | $172.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.19 / $235.33 / $459.69
| Professional | | $143.19 | $235.33 | $459.69 |