- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.13 / $202.71 / $936.84
| Professional | | $160.13 | $202.71 | $936.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $285.51 / $285.51 / $285.51
| Facility | | $285.51 | $285.51 | $285.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.58 / $270.39 / $321.26
| Professional | | $152.58 | $270.39 | $321.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.71 / $196.88 / $285.51
| Facility | | $141.71 | $196.88 | $285.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.98 / $285.51 / $404.60
| Professional | | $186.98 | $285.51 | $404.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.79 / $322.56 / $356.48
| Professional | | $261.79 | $322.56 | $356.48 |