- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.20 / $180.20 / $198.21
| Professional | | $180.20 | $180.20 | $198.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.63 / $562.63 / $562.63
| Facility | | $562.63 | $562.63 | $562.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.28 / $173.28 / $177.02
| Professional | | $173.28 | $173.28 | $177.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.81 / $203.81 / $203.81
| Facility | | $203.81 | $203.81 | $203.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.81 / $203.81 / $203.81
| Professional | | $203.81 | $203.81 | $203.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.03 / $163.16 / $250.31
| Professional | | $141.03 | $163.16 | $250.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.20 / $180.20 / $198.21
| Professional | | $180.20 | $180.20 | $198.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.26 / $181.97 / $272.95
| Professional | | $164.26 | $181.97 | $272.95 |