- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $237.14 / $394.60 / $1,790.84
| Facility | | $237.14 | $394.60 | $1,790.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.69 / $326.37 / $638.40
| Professional | | $313.69 | $326.37 | $638.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.23 / $292.31 / $321.54
| Professional | | $219.23 | $292.31 | $321.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.52 / $527.66 / $527.66
| Professional | | $448.52 | $527.66 | $527.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.33 / $359.05 / $366.23
| Professional | | $330.33 | $359.05 | $366.23 |