- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.86 / $202.49 / $275.85
| Professional | | $140.86 | $202.49 | $275.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.34 / $241.32 / $241.32
| Professional | | $170.34 | $241.32 | $241.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $244.43 / $244.43 / $244.43
| Facility | | $244.43 | $244.43 | $244.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.43 / $207.77 / $244.43
| Professional | | $178.43 | $207.77 | $244.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.43 / $295.44 / $1,550.44
| Facility | | $182.43 | $295.44 | $1,550.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.72 / $168.92 / $319.45
| Professional | | $132.72 | $168.92 | $319.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.03 / $165.14 / $319.45
| Professional | | $127.03 | $165.14 | $319.45 |