- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.87 / $178.87 / $784.30
| Professional | | $178.87 | $178.87 | $784.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $235.03 / $235.03 / $235.03
| Facility | | $235.03 | $235.03 | $235.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.15 / $235.03 / $247.93
| Professional | | $173.15 | $235.03 | $247.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.03 / $276.25 / $284.63
| Facility | | $116.03 | $276.25 | $284.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.40 / $210.62 / $303.80
| Professional | | $140.40 | $210.62 | $303.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.75 / $256.20 / $406.06
| Professional | | $216.75 | $256.20 | $406.06 |