- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $317.60 / $616.20 / $2,217.80
| Facility | | $317.60 | $616.20 | $2,217.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.25 / $317.60 / $317.60
| Professional | | $125.25 | $317.60 | $317.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $198.03 / $240.32 / $323.31
| Facility | | $198.03 | $240.32 | $323.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.82 / $183.82 / $216.91
| Professional | | $183.82 | $183.82 | $216.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.76 / $116.76 / $148.66
| Professional | | $116.76 | $116.76 | $148.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.37 / $137.37 / $158.30
| Professional | | $137.37 | $137.37 | $158.30 |