- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.94 / $177.47 / $852.97
| Professional | | $142.94 | $177.47 | $852.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $272.36 / $272.36 / $272.36
| Facility | | $272.36 | $272.36 | $272.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.86 / $245.12 / $323.01
| Professional | | $130.86 | $245.12 | $323.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $135.94 / $181.04 / $272.36
| Facility | | $135.94 | $181.04 | $272.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.04 / $272.36 / $406.83
| Professional | | $171.04 | $272.36 | $406.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.37 / $319.00 / $365.71
| Professional | | $267.37 | $319.00 | $365.71 |