- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.49 / $565.67 / $1,305.81
| Professional | | $124.49 | $565.67 | $1,305.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.41 / $171.41 / $171.41
| Facility | | $171.41 | $171.41 | $171.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.29 / $171.41 / $366.48
| Professional | | $118.29 | $171.41 | $366.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.41 / $343.20 / $376.34
| Facility | | $171.41 | $343.20 | $376.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.61 / $228.90 / $438.90
| Professional | | $114.61 | $228.90 | $438.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.35 / $415.95 / $645.64
| Professional | | $331.35 | $415.95 | $645.64 |