- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.60 / $214.42 / $429.25
| Professional | | $166.60 | $214.42 | $429.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,987.93 / $1,987.93 / $2,111.61
| Facility | | $1,987.93 | $1,987.93 | $2,111.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.78 / $310.55 / $929.60
| Professional | | $255.78 | $310.55 | $929.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.73 / $244.45 / $648.96
| Professional | | $178.73 | $244.45 | $648.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.43 / $327.63 / $648.96
| Professional | | $222.43 | $327.63 | $648.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.88 / $314.51 / $914.30
| Professional | | $235.88 | $314.51 | $914.30 |