- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $107.15 / $489.78
| Professional | | $79.43 | $107.15 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $602.56 / $602.56
| Facility | | $489.78 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $144.54 / $181.97
| Professional | | $93.33 | $144.54 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $177.83 / $257.04
| Professional | | $128.82 | $177.83 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $151.36 / $288.40
| Professional | | $128.82 | $151.36 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $128.82 / $489.78
| Professional | | $102.33 | $128.82 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $144.54 / $263.03
| Professional | | $117.49 | $144.54 | $263.03 |