- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.50 / $130.50 / $228.53
| Professional | | $130.50 | $130.50 | $228.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $254.87 / $254.87 / $254.87
| Facility | | $254.87 | $254.87 | $254.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.87 / $254.87 / $254.87
| Professional | | $254.87 | $254.87 | $254.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.10 / $225.10 / $352.68
| Facility | | $225.10 | $225.10 | $352.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.32 / $164.32 / $225.10
| Professional | | $164.32 | $164.32 | $225.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.06 / $172.06 / $172.06
| Facility | | $172.06 | $172.06 | $172.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.68 / $173.61 / $200.64
| Professional | | $117.68 | $173.61 | $200.64 |