- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.18 / $172.69 / $283.98
| Professional | | $161.18 | $172.69 | $283.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $301.27 / $301.27 / $301.27
| Facility | | $301.27 | $301.27 | $301.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.01 / $301.27 / $326.50
| Professional | | $163.01 | $301.27 | $326.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.69 / $203.09 / $301.27
| Facility | | $147.69 | $203.09 | $301.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.81 / $301.27 / $393.40
| Professional | | $181.81 | $301.27 | $393.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.22 / $317.49 / $353.93
| Professional | | $266.22 | $317.49 | $353.93 |