- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.65 / $202.74 / $266.93
| Professional | | $196.65 | $202.74 | $266.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $636.33 / $859.46 / $1,017.49
| Facility | | $636.33 | $859.46 | $1,017.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.41 / $253.42 / $407.01
| Professional | | $215.41 | $253.42 | $407.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.35 / $271.68 / $271.68
| Facility | | $260.35 | $271.68 | $271.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.33 / $271.68 / $271.68
| Professional | | $198.33 | $271.68 | $271.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.94 / $253.06 / $374.23
| Professional | | $202.94 | $253.06 | $374.23 |