- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.88 / $201.54 / $225.10
| Professional | | $158.88 | $201.54 | $225.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $294.19 / $321.33 / $435.86
| Facility | | $294.19 | $321.33 | $435.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.06 / $282.77 / $596.00
| Professional | | $257.06 | $282.77 | $596.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $283.73 / $283.73 / $283.73
| Facility | | $283.73 | $283.73 | $283.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.60 / $104.60 / $104.60
| Professional | | $104.60 | $104.60 | $104.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.00 / $76.00 / $93.00
| Professional | | $76.00 | $76.00 | $93.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.72 / $128.25 / $214.71
| Professional | | $108.72 | $128.25 | $214.71 |