- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.17 / $268.44 / $333.20
| Professional | | $126.17 | $268.44 | $333.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.30 / $1,076.30 / $1,076.30
| Professional | | $1,076.30 | $1,076.30 | $1,076.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.25 / $47.25 / $47.25
| Facility | | $47.25 | $47.25 | $47.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.97 / $34.97 / $34.97
| Professional | | $34.97 | $34.97 | $34.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $209.52 / $209.52 / $436.75
| Facility | | $209.52 | $209.52 | $436.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.65 / $209.52 / $290.14
| Professional | | $31.65 | $209.52 | $290.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.60 / $208.17 / $378.23
| Professional | | $126.60 | $208.17 | $378.23 |