- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.35 / $203.19 / $1,235.40
| Facility | | $182.35 | $203.19 | $1,235.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.19 / $203.19 / $208.40
| Professional | | $203.19 | $203.19 | $208.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.50 / $273.52 / $359.49
| Professional | | $260.50 | $273.52 | $359.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $473.45 / $641.76 / $1,485.36
| Facility | | $473.45 | $641.76 | $1,485.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.59 / $260.50 / $278.74
| Facility | | $200.59 | $260.50 | $278.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.41 / $148.58 / $237.21
| Professional | | $109.41 | $148.58 | $237.21 |