- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.37 / $196.40 / $196.40
| Professional | | $141.37 | $196.40 | $196.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.77 / $372.85 / $691.15
| Facility | | $287.77 | $372.85 | $691.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.71 / $206.48 / $206.48
| Professional | | $192.71 | $206.48 | $206.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $226.83 / $268.08 / $268.08
| Facility | | $226.83 | $268.08 | $268.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.70 / $195.70 / $268.08
| Professional | | $195.70 | $195.70 | $268.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.98 / $261.98 / $261.98
| Professional | | $261.98 | $261.98 | $261.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.18 / $196.40 / $196.40
| Professional | | $182.18 | $196.40 | $196.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.37 / $161.41 / $448.02
| Professional | | $124.37 | $161.41 | $448.02 |