- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.91 / $307.56 / $1,159.39
| Professional | | $143.91 | $307.56 | $1,159.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.73 / $218.73 / $218.73
| Facility | | $218.73 | $218.73 | $218.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.40 / $218.73 / $371.32
| Professional | | $126.40 | $218.73 | $371.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.25 / $188.76 / $276.79
| Facility | | $109.25 | $188.76 | $276.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.73 / $276.89 / $427.63
| Professional | | $166.73 | $276.89 | $427.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.33 / $354.54 / $410.52
| Professional | | $292.33 | $354.54 | $410.52 |