- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.27 / $225.66 / $225.66
| Professional | | $174.27 | $225.66 | $225.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $541.99 / $748.65 / $1,228.69
| Facility | | $541.99 | $748.65 | $1,228.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.01 / $242.37 / $359.90
| Professional | | $206.01 | $242.37 | $359.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.46 / $330.80 / $445.74
| Professional | | $238.46 | $330.80 | $445.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.87 / $245.13 / $459.93
| Professional | | $211.87 | $245.13 | $459.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.27 / $225.66 / $282.27
| Professional | | $174.27 | $225.66 | $282.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.07 / $244.43 / $386.40
| Professional | | $157.07 | $244.43 | $386.40 |