- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.75 / $209.42 / $209.42
| Professional | | $150.75 | $209.42 | $209.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.85 / $397.56 / $736.94
| Facility | | $306.85 | $397.56 | $736.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.80 / $166.45 / $166.45
| Professional | | $157.80 | $166.45 | $166.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.78 / $190.78 / $253.59
| Facility | | $190.78 | $190.78 | $253.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.27 / $139.27 / $190.78
| Professional | | $139.27 | $139.27 | $190.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $279.33 / $279.33 / $279.33
| Professional | | $279.33 | $279.33 | $279.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.65 / $209.42 / $209.42
| Professional | | $156.65 | $209.42 | $209.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.75 / $172.12 / $395.84
| Professional | | $114.75 | $172.12 | $395.84 |