- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $453.47 / $2,801.67 / $7,284.55
| Facility | | $453.47 | $2,801.67 | $7,284.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.44 / $176.45 / $1,264.43
| Professional | | $176.44 | $176.45 | $1,264.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $189.83 / $189.83 / $189.83
| Facility | | $189.83 | $189.83 | $189.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.45 / $176.45 / $176.45
| Professional | | $176.45 | $176.45 | $176.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.45 / $187.04 / $1,220.85
| Professional | | $176.45 | $187.04 | $1,220.85 |