- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $349.28 / $866.13 / $1,865.44
| Facility | | $349.28 | $866.13 | $1,865.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.90 / $211.12 / $211.12
| Professional | | $168.90 | $211.12 | $211.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.57 / $315.52 / $681.27
| Facility | | $139.57 | $315.52 | $681.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.48 / $304.06 / $576.27
| Professional | | $193.48 | $304.06 | $576.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.48 / $298.27 / $576.27
| Professional | | $193.48 | $298.27 | $576.27 |