- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $144.54 / $165.96
| Professional | | $77.62 | $144.54 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $173.78 / $177.83
| Professional | | $141.25 | $173.78 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $81.28 / $128.82
| Professional | | $81.28 | $81.28 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $154.88 / $208.93
| Facility | | $128.82 | $154.88 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $79.43 / $91.20
| Professional | | $56.23 | $79.43 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $891.25
| Facility | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,698.24
| Professional | | $1,071.52 | $1,071.52 | $1,698.24 |