- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.27 / $235.83 / $422.65
| Professional | | $156.27 | $235.83 | $422.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.77 / $172.77 / $172.77
| Facility | | $172.77 | $172.77 | $172.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.85 / $172.77 / $592.50
| Professional | | $146.85 | $172.77 | $592.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $391.48 / $391.48 / $391.48
| Professional | | $391.48 | $391.48 | $391.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $339.52 / $339.52 / $339.52
| Professional | | $339.52 | $339.52 | $339.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.22 / $250.61 / $469.97
| Professional | | $196.22 | $250.61 | $469.97 |