- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.81 / $561.89 / $612.24
| Professional | | $109.81 | $561.89 | $612.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.36 / $170.36 / $170.36
| Facility | | $170.36 | $170.36 | $170.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.81 / $186.13 / $201.37
| Professional | | $144.81 | $186.13 | $201.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $96.92 / $126.11 / $238.34
| Facility | | $96.92 | $126.11 | $238.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.26 / $175.78 / $225.92
| Professional | | $114.26 | $175.78 | $225.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.03 / $204.73 / $219.93
| Professional | | $186.03 | $204.73 | $219.93 |