- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.76 / $456.71 / $3,523.60
| Facility | | $156.76 | $456.71 | $3,523.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.11 / $177.71 / $178.06
| Professional | | $151.11 | $177.71 | $178.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.73 / $227.68 / $487.10
| Professional | | $165.73 | $227.68 | $487.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,129.03 / $1,129.03 / $3,183.86
| Facility | | $1,129.03 | $1,129.03 | $3,183.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.90 / $234.34 / $417.91
| Professional | | $180.90 | $234.34 | $417.91 |