- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.10 / $202.81 / $276.64
| Professional | | $136.10 | $202.81 | $276.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.35 / $303.87 / $303.87
| Facility | | $118.35 | $303.87 | $303.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.57 / $396.65 / $396.65
| Professional | | $381.57 | $396.65 | $396.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66.92 / $106.19 / $141.18
| Facility | | $66.92 | $106.19 | $141.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.20 / $164.40 / $198.10
| Professional | | $111.20 | $164.40 | $198.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66.92 / $106.19 / $141.18
| Facility | | $66.92 | $106.19 | $141.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.76 / $86.76 / $86.76
| Professional | | $86.76 | $86.76 | $86.76 |