- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.25 / $235.41 / $235.41
| Professional | | $170.25 | $235.41 | $235.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $310.87 / $402.76 / $746.60
| Facility | | $310.87 | $402.76 | $746.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.45 / $204.15 / $262.41
| Professional | | $195.45 | $204.15 | $262.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $231.66 / $231.66 / $231.66
| Facility | | $231.66 | $231.66 | $231.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.11 / $169.11 / $231.66
| Professional | | $169.11 | $169.11 | $231.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.00 / $283.00 / $283.00
| Professional | | $283.00 | $283.00 | $283.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.81 / $235.41 / $235.41
| Professional | | $196.81 | $235.41 | $235.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.25 / $174.38 / $401.01
| Professional | | $116.25 | $174.38 | $401.01 |