- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.81 / $197.32 / $264.27
| Professional | | $140.81 | $197.32 | $264.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.44 / $282.44 / $282.44
| Professional | | $282.44 | $282.44 | $282.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.52 / $283.52 / $283.52
| Professional | | $283.52 | $283.52 | $283.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.05 / $204.05 / $273.18
| Facility | | $204.05 | $204.05 | $273.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.44 / $244.85 / $437.34
| Professional | | $173.44 | $244.85 | $437.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.53 / $165.00 / $219.99
| Facility | | $18.53 | $165.00 | $219.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.44 / $166.51 / $295.88
| Professional | | $105.44 | $166.51 | $295.88 |