- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $194.98 / $346.74
| Professional | | $151.36 | $194.98 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $316.23 / $316.23
| Facility | | $316.23 | $316.23 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $316.23 / $316.23
| Professional | | $316.23 | $316.23 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $263.03 / $346.74
| Facility | | $263.03 | $263.03 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $194.98 / $309.03
| Professional | | $194.98 | $194.98 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.82 / $204.17 / $257.04
| Facility | | $114.82 | $204.17 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $154.88 / $234.42
| Professional | | $138.04 | $154.88 | $234.42 |