- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.34 / $133.38 / $168.78
| Professional | | $124.34 | $133.38 | $168.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $402.37 / $543.44 / $643.36
| Facility | | $402.37 | $543.44 | $643.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.12 / $149.55 / $250.12
| Professional | | $127.12 | $149.55 | $250.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.76 / $138.76 / $164.61
| Facility | | $138.76 | $138.76 | $164.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.29 / $138.76 / $138.76
| Professional | | $101.29 | $138.76 | $138.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $296.08 / $296.08 / $296.08
| Facility | | $296.08 | $296.08 | $296.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.32 / $160.02 / $236.63
| Professional | | $128.32 | $160.02 | $236.63 |