- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.87 / $193.49 / $333.85
| Professional | | $155.87 | $193.49 | $333.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.78 / $243.78 / $326.36
| Facility | | $243.78 | $243.78 | $326.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.21 / $243.78 / $430.88
| Professional | | $207.21 | $243.78 | $430.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.33 / $310.33 / $464.86
| Professional | | $310.33 | $310.33 | $464.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.54 / $249.54 / $249.54
| Professional | | $249.54 | $249.54 | $249.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.41 / $218.34 / $411.46
| Professional | | $181.41 | $218.34 | $411.46 |