- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.78 / $94.24 / $94.24
| Professional | | $87.78 | $94.24 | $94.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $418.73 / $918.41 / $1,856.79
| Facility | | $418.73 | $918.41 | $1,856.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.65 / $111.65 / $1,955.40
| Facility | | $111.65 | $111.65 | $1,955.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.87 / $76.41 / $108.04
| Professional | | $48.87 | $76.41 | $108.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.65 / $111.65 / $1,955.40
| Facility | | $111.65 | $111.65 | $1,955.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.87 / $76.41 / $108.04
| Professional | | $48.87 | $76.41 | $108.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.50 / $45.26 / $105.62
| Professional | | $31.50 | $45.26 | $105.62 |