- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.26 / $240.44 / $248.83
| Professional | | $157.26 | $240.44 | $248.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $279.58 / $279.58 / $279.58
| Professional | | $279.58 | $279.58 | $279.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.94 / $114.94 / $114.94
| Professional | | $114.94 | $114.94 | $114.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $215.26 / $240.44 / $315.08
| Facility | | $215.26 | $240.44 | $315.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.64 / $148.54 / $323.22
| Professional | | $79.64 | $148.54 | $323.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.64 / $119.47 / $171.39
| Professional | | $79.64 | $119.47 | $171.39 |