- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.98 / $325.39 / $412.52
| Professional | | $198.98 | $325.39 | $412.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $63.30 / $63.30 / $63.30
| Facility | | $63.30 | $63.30 | $63.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.21 / $45.21 / $45.21
| Professional | | $45.21 | $45.21 | $45.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $264.39 / $382.81 / $517.83
| Facility | | $264.39 | $382.81 | $517.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.29 / $382.81 / $382.81
| Professional | | $40.29 | $382.81 | $382.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.36 / $211.22 / $383.78
| Professional | | $144.36 | $211.22 | $383.78 |