- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $275.42 / $363.08
| Professional | | $190.55 | $275.42 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $371.54
| Facility | | $354.81 | $354.81 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $257.04 / $363.08
| Professional | | $257.04 | $257.04 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $489.78 / $616.60
| Professional | | $398.11 | $489.78 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.09 / $234.42 / $309.03
| Facility | | $229.09 | $234.42 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $354.81 / $1,047.13
| Professional | | $173.78 | $354.81 | $1,047.13 |