- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.62 / $150.88 / $150.88
| Professional | | $108.62 | $150.88 | $150.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $221.10 / $286.45 / $530.99
| Facility | | $221.10 | $286.45 | $530.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.76 / $118.98 / $118.98
| Professional | | $111.76 | $118.98 | $118.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.51 / $116.51 / $116.51
| Facility | | $116.51 | $116.51 | $116.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.05 / $85.05 / $116.51
| Professional | | $85.05 | $85.05 | $116.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.28 / $201.28 / $201.28
| Professional | | $201.28 | $201.28 | $201.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.97 / $150.88 / $150.88
| Professional | | $139.97 | $150.88 | $150.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $59.25 / $92.18 / $92.18
| Facility | | $59.25 | $92.18 | $92.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.68 / $124.02 / $285.22
| Professional | | $82.68 | $124.02 | $285.22 |