- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.02 / $259.02 / $323.79
| Professional | | $259.02 | $259.02 | $323.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $216.02 / $677.49 / $720.72
| Facility | | $216.02 | $677.49 | $720.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.62 / $86.60 / $710.30
| Professional | | $60.62 | $86.60 | $710.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.16 / $236.71 / $312.58
| Facility | | $171.16 | $236.71 | $312.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.16 / $255.01 / $365.13
| Professional | | $171.16 | $255.01 | $365.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.88 / $166.88 / $290.97
| Professional | | $166.88 | $166.88 | $290.97 |