- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.87 / $212.71 / $212.71
| Professional | | $179.87 | $212.71 | $212.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $527.67 / $728.88 / $1,196.24
| Facility | | $527.67 | $728.88 | $1,196.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.12 / $219.26 / $274.68
| Professional | | $170.12 | $219.26 | $274.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.79 / $256.51 / $394.75
| Professional | | $167.79 | $256.51 | $394.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.41 / $187.91 / $352.56
| Professional | | $162.41 | $187.91 | $352.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.87 / $212.71 / $217.23
| Professional | | $179.87 | $212.71 | $217.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.19 / $251.60 / $325.35
| Professional | | $148.19 | $251.60 | $325.35 |