- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.37 / $140.91 / $204.45
| Professional | | $127.37 | $140.91 | $204.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $216.42 / $216.42 / $244.45
| Facility | | $216.42 | $216.42 | $244.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.99 / $157.99 / $244.45
| Professional | | $157.99 | $157.99 | $244.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.98 / $212.81 / $216.64
| Professional | | $208.98 | $212.81 | $216.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.25 / $153.02 / $153.02
| Facility | | $0.25 | $153.02 | $153.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.92 / $154.40 / $232.58
| Professional | | $127.92 | $154.40 | $232.58 |