- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.15 / $172.47 / $172.47
| Professional | | $124.15 | $172.47 | $172.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.71 / $327.41 / $606.91
| Facility | | $252.71 | $327.41 | $606.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.22 / $147.91 / $147.91
| Professional | | $139.22 | $147.91 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.84 / $144.84 / $208.84
| Facility | | $144.84 | $144.84 | $208.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.73 / $105.73 / $144.84
| Professional | | $105.73 | $105.73 | $144.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.06 / $230.06 / $230.06
| Professional | | $230.06 | $230.06 | $230.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.21 / $172.47 / $172.47
| Professional | | $139.21 | $172.47 | $172.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.50 / $141.76 / $326.00
| Professional | | $94.50 | $141.76 | $326.00 |