- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.63 / $159.43 / $176.60
| Professional | | $95.63 | $159.43 | $176.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $653.60 / $653.60 / $653.60
| Facility | | $653.60 | $653.60 | $653.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.14 / $282.77 / $282.77
| Professional | | $276.14 | $282.77 | $282.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.80 / $101.80 / $101.80
| Professional | | $101.80 | $101.80 | $101.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.61 / $226.61 / $226.61
| Professional | | $226.61 | $226.61 | $226.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.63 / $159.43 / $176.60
| Professional | | $95.63 | $159.43 | $176.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.81 / $138.63 / $231.06
| Professional | | $105.81 | $138.63 | $231.06 |