- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.74 / $89.74 / $102.43
| Professional | | $89.74 | $89.74 | $102.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $351.78 / $485.92 / $797.50
| Facility | | $351.78 | $485.92 | $797.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.08 / $105.98 / $146.87
| Professional | | $90.08 | $105.98 | $146.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.25 / $142.46 / $183.97
| Professional | | $96.25 | $142.46 | $183.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.65 / $134.96 / $253.22
| Professional | | $116.65 | $134.96 | $253.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.74 / $89.74 / $155.49
| Professional | | $89.74 | $89.74 | $155.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.70 / $149.54 / $199.52
| Professional | | $88.70 | $149.54 | $199.52 |