- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.22 / $148.22 / $175.43
| Professional | | $129.22 | $148.22 | $175.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.30 / $164.30 / $164.30
| Professional | | $164.30 | $164.30 | $164.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.17 / $189.32 / $189.32
| Professional | | $174.17 | $189.32 | $189.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $409.66 / $409.66 / $409.66
| Facility | | $409.66 | $409.66 | $409.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.68 / $130.68 / $203.75
| Facility | | $130.68 | $130.68 | $203.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.08 / $130.68 / $241.50
| Professional | | $111.08 | $130.68 | $241.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.54 / $110.03 / $158.97
| Professional | | $71.54 | $110.03 | $158.97 |