- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.79 / $196.79 / $205.06
| Professional | | $196.79 | $196.79 | $205.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $646.39 / $892.86 / $1,465.37
| Facility | | $646.39 | $892.86 | $1,465.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.60 / $203.06 / $295.02
| Professional | | $172.60 | $203.06 | $295.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.84 / $280.19 / $385.02
| Professional | | $195.84 | $280.19 | $385.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.20 / $218.90 / $410.72
| Professional | | $189.20 | $218.90 | $410.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.79 / $196.79 / $252.06
| Professional | | $196.79 | $196.79 | $252.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.03 / $295.05 / $381.53
| Professional | | $161.03 | $295.05 | $381.53 |