- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.34 / $191.67 / $191.67
| Professional | | $124.34 | $191.67 | $191.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.11 / $327.92 / $607.86
| Facility | | $253.11 | $327.92 | $607.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.38 / $141.71 / $213.65
| Professional | | $133.38 | $141.71 | $213.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.76 / $138.76 / $209.16
| Facility | | $138.76 | $138.76 | $209.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.29 / $101.29 / $138.76
| Professional | | $101.29 | $101.29 | $138.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.42 / $230.42 / $230.42
| Professional | | $230.42 | $230.42 | $230.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.24 / $191.67 / $191.67
| Professional | | $160.24 | $191.67 | $191.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.65 / $170.72 / $394.07
| Professional | | $94.65 | $170.72 | $394.07 |