- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.74 / $1,771.84 / $4,412.62
| Facility | | $165.74 | $1,771.84 | $4,412.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.54 / $165.74 / $173.63
| Professional | | $153.54 | $165.74 | $173.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.61 / $257.39 / $305.38
| Professional | | $156.61 | $257.39 | $305.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,660.87 / $1,660.87 / $1,660.87
| Facility | | $1,660.87 | $1,660.87 | $1,660.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.81 / $256.57 / $402.42
| Professional | | $196.81 | $256.57 | $402.42 |