- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.51 / $302.51 / $302.51
| Professional | | $181.51 | $302.51 | $302.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $215.87 / $215.87 / $288.92
| Facility | | $215.87 | $215.87 | $288.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.59 / $215.87 / $230.13
| Professional | | $157.59 | $215.87 | $230.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.27 / $243.36 / $345.48
| Facility | | $111.27 | $243.36 | $345.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.93 / $328.21 / $345.48
| Professional | | $310.93 | $328.21 | $345.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $258.08 / $310.93
| Professional | | $30.00 | $258.08 | $310.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.51 / $337.38 / $506.07
| Facility | | $302.51 | $337.38 | $506.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.84 / $241.84 / $362.75
| Professional | | $241.84 | $241.84 | $362.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.36 / $172.36 / $267.72
| Professional | | $159.36 | $172.36 | $267.72 |