- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $138.04 / $194.98
| Professional | | $109.65 | $138.04 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $691.83
| Facility | | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,445.44
| Facility | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $186.21 / $457.09
| Professional | | $144.54 | $186.21 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $138.04 / $457.09
| Professional | | $138.04 | $138.04 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $144.54 / $371.54
| Professional | | $117.49 | $144.54 | $371.54 |