- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.08 / $219.72 / $292.95
| Professional | | $157.08 | $219.72 | $292.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.34 / $240.34 / $288.88
| Facility | | $240.34 | $240.34 | $288.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.29 / $240.34 / $247.55
| Professional | | $204.29 | $240.34 | $247.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.70 / $361.64 / $414.25
| Professional | | $218.70 | $361.64 | $414.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.88 / $238.38 / $297.98
| Professional | | $163.88 | $238.38 | $297.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.36 / $208.08 / $295.07
| Professional | | $163.36 | $208.08 | $295.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.98 / $297.98 / $297.98
| Professional | | $297.98 | $297.98 | $297.98 |