- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.84 / $290.33 / $1,404.21
| Professional | | $212.84 | $290.33 | $1,404.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.42 / $426.42 / $426.42
| Facility | | $426.42 | $426.42 | $426.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.22 / $426.42 / $789.20
| Professional | | $262.22 | $426.42 | $789.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $262.70 / $381.73 / $469.95
| Facility | | $262.70 | $381.73 | $469.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.49 / $438.37 / $730.48
| Professional | | $284.49 | $438.37 | $730.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.94 / $455.65 / $578.88
| Professional | | $376.94 | $455.65 | $578.88 |