- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $194.98 / $263.03
| Professional | | $138.04 | $194.98 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $154.88 / $177.83
| Professional | | $120.23 | $154.88 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $707.95 / $707.95
| Facility | | $707.95 | $707.95 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $213.80 / $281.84
| Professional | | $151.36 | $213.80 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $186.21 / $281.84
| Professional | | $158.49 | $186.21 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $194.98 / $288.40
| Professional | | $138.04 | $194.98 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $204.17 / $269.15
| Professional | | $123.03 | $204.17 | $269.15 |