- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.88 / $305.64 / $305.64
| Professional | | $228.88 | $305.64 | $305.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.93 / $315.80 / $389.08
| Professional | | $314.93 | $315.80 | $389.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $256.50 / $256.50 / $466.38
| Facility | | $256.50 | $256.50 | $466.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.83 / $256.50 / $478.03
| Professional | | $35.83 | $256.50 | $478.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.88 / $225.68 / $305.64
| Professional | | $172.88 | $225.68 | $305.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.37 / $265.75 / $598.78
| Professional | | $122.37 | $265.75 | $598.78 |