- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.85 / $224.18 / $258.83
| Professional | | $196.85 | $224.18 | $258.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29.82 / $230.74 / $307.66
| Facility | | $29.82 | $230.74 | $307.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.09 / $242.25 / $331.32
| Professional | | $26.09 | $242.25 | $331.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.17 / $243.17 / $476.64
| Facility | | $243.17 | $243.17 | $476.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.17 / $292.92 / $319.16
| Professional | | $243.17 | $292.92 | $319.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.61 / $319.61 / $319.61
| Professional | | $319.61 | $319.61 | $319.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.93 / $223.61 / $393.04
| Professional | | $192.93 | $223.61 | $393.04 |