- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $177.83 / $398.11
| Professional | | $123.03 | $177.83 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $512.86
| Facility | | $398.11 | $398.11 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $190.55
| Professional | | $162.18 | $162.18 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $194.98 / $281.84
| Professional | | $123.03 | $194.98 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $204.17 / $245.47
| Professional | | $147.91 | $204.17 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $177.83 / $354.81
| Professional | | $147.91 | $177.83 | $354.81 |