- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.56 / $153.90 / $224.37
| Professional | | $136.56 | $153.90 | $224.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $249.23 / $249.23 / $249.23
| Facility | | $249.23 | $249.23 | $249.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.50 / $249.23 / $249.23
| Professional | | $176.50 | $249.23 | $249.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.22 / $166.05 / $249.23
| Facility | | $130.22 | $166.05 | $249.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.53 / $238.32 / $280.38
| Professional | | $145.53 | $238.32 | $280.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.41 / $298.70 / $371.72
| Professional | | $272.41 | $298.70 | $371.72 |