- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.32 / $207.32 / $207.32
| Professional | | $207.32 | $207.32 | $207.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.16 / $232.27 / $244.50
| Professional | | $215.16 | $232.27 | $244.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.77 / $153.77 / $207.19
| Facility | | $153.77 | $153.77 | $207.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.77 / $202.74 / $325.91
| Professional | | $153.77 | $202.74 | $325.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.26 / $207.32 / $1,123.95
| Facility | | $20.26 | $207.32 | $1,123.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.27 / $95.86 / $159.76
| Professional | | $60.27 | $95.86 | $159.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.46 / $27.54 / $52.62
| Facility | | $27.46 | $27.54 | $52.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.54 / $34.42 / $65.09
| Professional | | $27.54 | $34.42 | $65.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.16 / $95.86 / $159.76
| Professional | | $61.16 | $95.86 | $159.76 |