- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $281.84 / $354.81
| Professional | | $281.84 | $281.84 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.21 / $537.03 / $537.03
| Facility | | $186.21 | $537.03 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $323.59 / $549.54
| Professional | | $138.04 | $323.59 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $186.21 / $199.53
| Professional | | $186.21 | $186.21 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $229.09 / $239.88
| Professional | | $199.53 | $229.09 | $239.88 |