- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.68 / $198.23 / $336.80
| Professional | | $159.68 | $198.23 | $336.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.42 / $243.42 / $325.88
| Facility | | $243.42 | $243.42 | $325.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.91 / $243.42 / $431.25
| Professional | | $206.91 | $243.42 | $431.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.20 / $295.20 / $476.25
| Professional | | $295.20 | $295.20 | $476.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.57 / $243.57 / $243.57
| Professional | | $243.57 | $243.57 | $243.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.33 / $213.12 / $333.14
| Professional | | $170.33 | $213.12 | $333.14 |