- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.68 / $349.77 / $1,283.25
| Professional | | $190.68 | $349.77 | $1,283.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $301.81 / $301.81 / $301.81
| Facility | | $301.81 | $301.81 | $301.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.42 / $278.93 / $387.61
| Professional | | $172.42 | $278.93 | $387.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.32 / $212.71 / $336.02
| Facility | | $150.32 | $212.71 | $336.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.24 / $323.58 / $490.82
| Professional | | $202.24 | $323.58 | $490.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.08 / $381.70 / $439.85
| Professional | | $285.08 | $381.70 | $439.85 |