- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.78 / $134.58 / $134.58
| Professional | | $114.78 | $134.58 | $134.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.73 / $230.26 / $426.84
| Facility | | $177.73 | $230.26 | $426.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.08 / $127.52 / $150.02
| Professional | | $122.08 | $127.52 | $150.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.08 / $172.35 / $172.35
| Facility | | $140.08 | $172.35 | $172.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.82 / $125.82 / $172.35
| Professional | | $125.82 | $125.82 | $172.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.79 / $161.79 / $161.79
| Professional | | $161.79 | $161.79 | $161.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.52 / $134.58 / $134.58
| Professional | | $112.52 | $134.58 | $134.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $63.50 / $131.74 / $131.74
| Facility | | $63.50 | $131.74 | $131.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.45 / $150.19 / $276.69
| Professional | | $66.45 | $150.19 | $276.69 |