- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $257.04 / $316.23
| Professional | | $245.47 | $257.04 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $234.42
| Professional | | $151.36 | $151.36 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.15 / $173.78 / $245.47
| Facility | | $107.15 | $173.78 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $478.63 / $489.78
| Professional | | $173.78 | $478.63 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $173.78
| Professional | | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $208.93 / $213.80
| Professional | | $208.93 | $208.93 | $213.80 |