- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $268.56 / $315.27 / $663.08
| Facility | | $268.56 | $315.27 | $663.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.54 / $228.37 / $258.01
| Professional | | $215.54 | $228.37 | $258.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,196.11 / $2,196.11 / $2,196.11
| Facility | | $2,196.11 | $2,196.11 | $2,196.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.72 / $298.64 / $409.77
| Professional | | $190.72 | $298.64 | $409.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.07 / $255.76 / $638.88
| Professional | | $189.07 | $255.76 | $638.88 |