- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.31 / $157.63 / $244.43
| Professional | | $143.31 | $157.63 | $244.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.07 / $246.07 / $246.07
| Facility | | $246.07 | $246.07 | $246.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.26 / $246.07 / $264.23
| Professional | | $178.26 | $246.07 | $264.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.66 / $273.64 / $293.48
| Facility | | $121.66 | $273.64 | $293.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.19 / $220.81 / $318.50
| Professional | | $147.19 | $220.81 | $318.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.70 / $266.39 / $429.21
| Professional | | $214.70 | $266.39 | $429.21 |