- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $2,137.96 / $2,290.87
| Facility | | $173.78 | $2,137.96 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $173.78 / $309.03
| Professional | | $144.54 | $173.78 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,818.38 / $4,570.88
| Facility | | $1,819.70 | $2,818.38 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $245.47
| Facility | | $173.78 | $173.78 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61.66 / $213.80 / $363.08
| Facility | | $61.66 | $213.80 | $363.08 |