- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $154.88 / $213.80
| Professional | | $104.71 | $154.88 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $331.13
| Facility | | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $275.42 / $275.42
| Professional | | $275.42 | $275.42 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.36 / $56.23 / $120.23
| Facility | | $32.36 | $56.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $60.26
| Professional | | $60.26 | $60.26 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $144.54 / $173.78
| Professional | | $47.86 | $144.54 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.36 / $56.23 / $120.23
| Facility | | $32.36 | $56.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $60.26
| Professional | | $60.26 | $60.26 | $60.26 |