- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.65 / $208.02 / $1,100.08
| Professional | | $161.65 | $208.02 | $1,100.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $337.56 / $337.56 / $337.56
| Facility | | $337.56 | $337.56 | $337.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.89 / $337.56 / $558.91
| Professional | | $191.89 | $337.56 | $558.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $149.13 / $254.77 / $361.16
| Facility | | $149.13 | $254.77 | $361.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.76 / $343.38 / $571.45
| Professional | | $221.76 | $343.38 | $571.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.58 / $337.70 / $443.18
| Professional | | $288.58 | $337.70 | $443.18 |