- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.90 / $223.35 / $403.60
| Professional | | $186.90 | $223.35 | $403.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.07 / $273.89 / $946.16
| Facility | | $121.07 | $273.89 | $946.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.40 / $256.91 / $1,172.58
| Professional | | $187.40 | $256.91 | $1,172.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $197.91 / $201.38 / $215.68
| Facility | | $197.91 | $201.38 | $215.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.35 / $252.55 / $460.18
| Professional | | $177.35 | $252.55 | $460.18 |