- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.37 / $151.63 / $151.63
| Professional | | $98.37 | $151.63 | $151.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.24 / $259.43 / $480.90
| Facility | | $200.24 | $259.43 | $480.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.91 / $143.66 / $169.02
| Professional | | $136.91 | $143.66 | $169.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.83 / $194.51 / $194.51
| Facility | | $157.83 | $194.51 | $194.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.99 / $141.99 / $194.51
| Professional | | $141.99 | $141.99 | $194.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.29 / $182.29 / $182.29
| Professional | | $182.29 | $182.29 | $182.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.77 / $151.63 / $151.63
| Professional | | $126.77 | $151.63 | $151.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.88 / $112.32 / $258.29
| Professional | | $74.88 | $112.32 | $258.29 |