- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $218.78 / $338.84
| Professional | | $165.96 | $218.78 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $263.03 / $263.03
| Facility | | $263.03 | $263.03 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $263.03 / $457.09
| Professional | | $223.87 | $263.03 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $371.54 / $457.09
| Professional | | $263.03 | $371.54 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $275.42 / $338.84
| Professional | | $275.42 | $275.42 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23.44 / $186.21 / $512.86
| Facility | | $23.44 | $186.21 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $245.47 / $426.58
| Professional | | $186.21 | $245.47 | $426.58 |