- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $151.36 / $204.17
| Professional | | $85.11 | $151.36 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $524.81 / $524.81
| Facility | | $524.81 | $524.81 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $257.04 / $295.12
| Professional | | $218.78 | $257.04 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $91.20 / $91.20
| Professional | | $72.44 | $91.20 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $190.55 / $190.55
| Professional | | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $151.36 / $204.17
| Professional | | $85.11 | $151.36 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $107.15 / $190.55
| Professional | | $72.44 | $107.15 | $190.55 |