- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $263.03 / $354.81
| Professional | | $173.78 | $263.03 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $389.05 / $389.05
| Facility | | $389.05 | $389.05 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $489.78 / $512.86
| Professional | | $489.78 | $489.78 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.20 / $169.82 / $281.84
| Facility | | $112.20 | $169.82 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $109.65
| Professional | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $229.09 / $263.03
| Professional | | $151.36 | $229.09 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $154.88 / $245.47
| Facility | | $109.65 | $154.88 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $109.65
| Professional | | $109.65 | $109.65 | $109.65 |