- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $160.18 / $266.30 / $4,129.22
| Facility | | $160.18 | $266.30 | $4,129.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.66 / $227.58 / $266.30
| Professional | | $155.66 | $227.58 | $266.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.34 / $245.73 / $347.84
| Professional | | $162.34 | $245.73 | $347.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.98 / $1,649.98 / $1,649.98
| Facility | | $1,649.98 | $1,649.98 | $1,649.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.04 / $284.48 / $625.86
| Professional | | $196.04 | $284.48 | $625.86 |