- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.61 / $260.52 / $355.37
| Professional | | $135.61 | $260.52 | $355.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.16 / $384.75 / $384.75
| Facility | | $151.16 | $384.75 | $384.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.34 / $511.57 / $511.57
| Professional | | $489.34 | $511.57 | $511.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.32 / $136.29 / $191.49
| Facility | | $105.32 | $136.29 | $191.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.69 / $211.70 / $255.10
| Professional | | $136.69 | $211.70 | $255.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.03 / $137.72 / $191.49
| Facility | | $110.03 | $137.72 | $191.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.64 / $110.64 / $110.64
| Professional | | $110.64 | $110.64 | $110.64 |