- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.53 / $184.78 / $198.90
| Professional | | $146.53 | $184.78 | $198.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $474.14 / $640.40 / $758.16
| Facility | | $474.14 | $640.40 | $758.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.51 / $188.83 / $303.26
| Professional | | $160.51 | $188.83 | $303.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.25 / $192.25 / $192.25
| Facility | | $192.25 | $192.25 | $192.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.34 / $192.25 / $192.25
| Professional | | $140.34 | $192.25 | $192.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.09 / $191.52 / $278.83
| Professional | | $130.09 | $191.52 | $278.83 |