- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $363.08 / $575.44
| Professional | | $234.42 | $363.08 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $144.54 / $158.49
| Professional | | $144.54 | $144.54 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.20 / $144.54 / $229.09
| Facility | | $91.20 | $144.54 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $275.42 / $275.42
| Professional | | $251.19 | $275.42 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $457.09 / $457.09
| Facility | | $457.09 | $457.09 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $575.44
| Professional | | $575.44 | $575.44 | $575.44 |