- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.79 / $313.17 / $413.87
| Professional | | $150.79 | $313.17 | $413.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.51 / $301.58 / $486.90
| Professional | | $155.51 | $301.58 | $486.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.28 / $175.28 / $175.28
| Professional | | $175.28 | $175.28 | $175.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $327.45 / $413.87 / $620.80
| Facility | | $327.45 | $413.87 | $620.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $486.90 / $632.97 / $964.06
| Professional | | $486.90 | $632.97 | $964.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.66 / $182.18 / $261.36
| Professional | | $164.66 | $182.18 | $261.36 |