- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $288.40 / $288.40
| Professional | | $234.42 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.05 / $29.51 / $29.51
| Professional | | $19.05 | $29.51 | $29.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $407.38
| Facility | | $407.38 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $407.38 / $407.38
| Professional | | $346.74 | $407.38 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.15 / $281.84 / $371.54
| Facility | | $37.15 | $281.84 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $295.12 / $489.78
| Professional | | $181.97 | $295.12 | $489.78 |