- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $91.20 / $208.93
| Professional | | $66.07 | $91.20 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.82 / $213.80 / $12,302.69
| Facility | | $169.82 | $213.80 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $131.83 / $131.83
| Professional | | $97.72 | $131.83 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $416.87
| Facility | | $151.36 | $151.36 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $158.49 / $204.17
| Professional | | $95.50 | $158.49 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $109.65
| Facility | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $109.65 / $151.36
| Professional | | $81.28 | $109.65 | $151.36 |