- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.88 / $228.16 / $926.48
| Professional | | $142.88 | $228.16 | $926.48 |
- 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
- $179.26 / $285.51 / $567.21
| Professional | | $179.26 | $285.51 | $567.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.55 / $251.73 / $465.52
| Facility | | $167.55 | $251.73 | $465.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.98 / $413.14 / $667.49
| Professional | | $241.98 | $413.14 | $667.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.56 / $417.94 / $527.62
| Professional | | $343.56 | $417.94 | $527.62 |