- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $362.82 / $1,901.18 / $2,492.57
| Facility | | $362.82 | $1,901.18 | $2,492.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.00 / $225.00 / $407.04
| Professional | | $225.00 | $225.00 | $407.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.07 / $143.07 / $143.07
| Facility | | $143.07 | $143.07 | $143.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.49 / $104.49 / $130.61
| Professional | | $104.49 | $104.49 | $130.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.73 / $323.85 / $471.95
| Facility | | $246.73 | $323.85 | $471.95 |