- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.68 / $267.74 / $1,353.32
| Facility | | $213.68 | $267.74 | $1,353.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.49 / $172.49 / $213.68
| Professional | | $172.49 | $172.49 | $213.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.34 / $167.34 / $167.34
| Facility | | $167.34 | $167.34 | $167.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.70 / $207.74 / $517.70
| Professional | | $184.70 | $207.74 | $517.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.36 / $633.46 / $1,721.72
| Facility | | $126.36 | $633.46 | $1,721.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.13 / $215.81 / $566.39
| Professional | | $108.13 | $215.81 | $566.39 |