- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.84 / $1,803.27 / $2,580.60
| Facility | | $154.84 | $1,803.27 | $2,580.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.54 / $207.65 / $241.94
| Professional | | $142.54 | $207.65 | $241.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.12 / $214.12 / $214.12
| Professional | | $214.12 | $214.12 | $214.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.78 / $195.78 / $195.78
| Facility | | $195.78 | $195.78 | $195.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.41 / $166.41 / $236.21
| Professional | | $166.41 | $166.41 | $236.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.93 / $134.97 / $187.87
| Professional | | $78.93 | $134.97 | $187.87 |