- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $177.83 / $309.03
| Professional | | $151.36 | $177.83 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $257.04 / $257.04
| Professional | | $257.04 | $257.04 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $204.17 / $588.84
| Facility | | $204.17 | $204.17 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $371.54
| Professional | | $151.36 | $151.36 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.15 / $186.21 / $426.58
| Facility | | $107.15 | $186.21 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $158.49 / $239.88
| Professional | | $104.71 | $158.49 | $239.88 |