- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.58 / $183.65 / $183.65
| Professional | | $164.58 | $183.65 | $183.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.20 / $288.20 / $288.20
| Professional | | $288.20 | $288.20 | $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
- $26.88 / $204.43 / $240.50
| Professional | | $26.88 | $204.43 | $240.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.70 / $171.71 / $305.02
| Professional | | $109.70 | $171.71 | $305.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.57 / $340.78 / $433.72
| Professional | | $307.57 | $340.78 | $433.72 |