- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.61 / $96.16 / $96.16
| Professional | | $69.61 | $96.16 | $96.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $531.34 / $531.34 / $531.34
| Facility | | $531.34 | $531.34 | $531.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $585.87 / $585.87 / $585.87
| Facility | | $585.87 | $585.87 | $585.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.40 / $139.52 / $294.10
| Professional | | $101.40 | $139.52 | $294.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $585.87 / $585.87 / $585.87
| Facility | | $585.87 | $585.87 | $585.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.40 / $139.52 / $294.10
| Professional | | $101.40 | $139.52 | $294.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.92 / $160.62 / $280.16
| Professional | | $85.92 | $160.62 | $280.16 |