- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.07 / $143.49 / $224.37
| Professional | | $134.07 | $143.49 | $224.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $250.23 / $250.23 / $250.23
| Facility | | $250.23 | $250.23 | $250.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.23 / $250.23 / $250.23
| Professional | | $250.23 | $250.23 | $250.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.31 / $124.31 / $214.81
| Facility | | $124.31 | $124.31 | $214.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.75 / $90.75 / $190.74
| Professional | | $90.75 | $90.75 | $190.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.65 / $95.87 / $106.44
| Professional | | $86.65 | $95.87 | $106.44 |