- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.76 / $591.32 / $591.32
| Professional | | $80.76 | $591.32 | $591.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.26 / $207.26 / $207.26
| Professional | | $207.26 | $207.26 | $207.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $149.11 / $222.84 / $222.84
| Facility | | $149.11 | $222.84 | $222.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.11 / $222.84 / $222.84
| Professional | | $149.11 | $222.84 | $222.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.56 / $212.23 / $222.84
| Facility | | $104.56 | $212.23 | $222.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.11 / $167.26 / $223.01
| Professional | | $149.11 | $167.26 | $223.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.56 / $93.57 / $143.18
| Professional | | $84.56 | $93.57 | $143.18 |