- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.95 / $153.37 / $184.26
| Professional | | $101.95 | $153.37 | $184.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $628.76 / $628.76 / $628.76
| Facility | | $628.76 | $628.76 | $628.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.39 / $301.45 / $301.45
| Professional | | $294.39 | $301.45 | $301.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.53 / $108.53 / $108.53
| Professional | | $108.53 | $108.53 | $108.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.00 / $218.00 / $218.00
| Professional | | $218.00 | $218.00 | $218.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.95 / $153.37 / $184.26
| Professional | | $101.95 | $153.37 | $184.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.42 / $133.37 / $306.72
| Professional | | $104.42 | $133.37 | $306.72 |