- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.72 / $158.72 / $289.30
| Professional | | $158.72 | $158.72 | $289.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.07 / $409.10 / $1,042.49
| Facility | | $246.07 | $409.10 | $1,042.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.69 / $128.69 / $246.07
| Professional | | $128.69 | $128.69 | $246.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.07 / $409.10 / $1,042.49
| Facility | | $246.07 | $409.10 | $1,042.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.69 / $214.48 / $294.27
| Professional | | $128.69 | $214.48 | $294.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.31 / $259.31 / $259.31
| Professional | | $259.31 | $259.31 | $259.31 |