- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.50 / $133.97 / $180.72
| Professional | | $106.50 | $133.97 | $180.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.27 / $174.27 / $174.27
| Facility | | $174.27 | $174.27 | $174.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.13 / $174.27 / $174.27
| Professional | | $148.13 | $174.27 | $174.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.79 / $217.89 / $248.82
| Professional | | $127.79 | $217.89 | $248.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.21 / $135.08 / $227.04
| Professional | | $20.21 | $135.08 | $227.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.34 / $117.41 / $172.42
| Professional | | $83.34 | $117.41 | $172.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.74 / $206.74 / $206.74
| Professional | | $206.74 | $206.74 | $206.74 |