- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.21 / $325.92 / $326.20
| Professional | | $243.21 | $325.92 | $326.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.76 / $307.75 / $307.75
| Professional | | $242.76 | $307.75 | $307.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.34 / $240.34 / $240.34
| Facility | | $240.34 | $240.34 | $240.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.29 / $240.34 / $240.34
| Professional | | $204.29 | $240.34 | $240.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.68 / $255.68 / $255.68
| Professional | | $255.68 | $255.68 | $255.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.19 / $212.10 / $300.69
| Professional | | $159.19 | $212.10 | $300.69 |