- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $181.97 / $223.87
| Professional | | $95.50 | $181.97 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $218.78 / $223.87
| Professional | | $173.78 | $218.78 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $165.96
| Professional | | $104.71 | $104.71 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.49 / $190.55 / $263.03
| Facility | | $158.49 | $190.55 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $97.72 / $114.82
| Professional | | $72.44 | $97.72 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $2,187.76
| Professional | | $1,380.38 | $1,380.38 | $2,187.76 |