- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $218.78 / $275.42
| Professional | | $151.36 | $218.78 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.09 / $229.09 / $363.08
| Facility | | $229.09 | $229.09 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $169.82 / $239.88
| Professional | | $169.82 | $169.82 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $389.05 / $489.78
| Professional | | $363.08 | $389.05 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.97 / $229.09 / $281.84
| Facility | | $181.97 | $229.09 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $295.12 / $1,023.29
| Professional | | $165.96 | $295.12 | $1,023.29 |