- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.13 / $197.32 / $261.33
| Professional | | $137.13 | $197.32 | $261.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.44 / $293.44 / $293.44
| Facility | | $293.44 | $293.44 | $293.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.44 / $293.44 / $293.44
| Professional | | $293.44 | $293.44 | $293.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.05 / $204.05 / $327.98
| Facility | | $204.05 | $204.05 | $327.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.44 / $173.44 / $244.85
| Professional | | $173.44 | $173.44 | $244.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.53 / $143.01 / $225.78
| Facility | | $18.53 | $143.01 | $225.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.44 / $184.51 / $398.38
| Professional | | $105.44 | $184.51 | $398.38 |