- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $205.10 / $320.11 / $770.06
| Facility | | $205.10 | $320.11 | $770.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.54 / $300.88 / $430.01
| Professional | | $178.54 | $300.88 | $430.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.74 / $292.12 / $606.35
| Facility | | $177.74 | $292.12 | $606.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.40 / $264.01 / $363.76
| Professional | | $160.40 | $264.01 | $363.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.22 / $145.75 / $323.42
| Facility | | $140.22 | $145.75 | $323.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,048.00 / $1,048.00 / $1,048.00
| Professional | | $1,048.00 | $1,048.00 | $1,048.00 |