- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.55 / $257.16 / $350.34
| Professional | | $165.55 | $257.16 | $350.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.13 / $257.18 / $288.20
| Professional | | $182.13 | $257.18 | $288.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.50 / $240.50 / $240.50
| Facility | | $240.50 | $240.50 | $240.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.06 / $240.50 / $240.50
| Professional | | $29.06 | $240.50 | $240.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.10 / $176.76 / $1,757.61
| Facility | | $20.10 | $176.76 | $1,757.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.86 / $172.80 / $324.82
| Professional | | $109.86 | $172.80 | $324.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.86 / $172.80 / $327.71
| Professional | | $109.86 | $172.80 | $327.71 |