- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $194.98 / $323.59
| Professional | | $162.18 | $194.98 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $275.42 / $371.54
| Professional | | $89.13 | $275.42 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $269.15 / $269.15
| Facility | | $269.15 | $269.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $269.15 / $549.54
| Professional | | $177.83 | $269.15 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $316.23 / $575.44
| Professional | | $128.82 | $316.23 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $229.09 / $741.31
| Professional | | $169.82 | $229.09 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $323.59 / $562.34
| Professional | | $218.78 | $323.59 | $562.34 |