- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $4,466.84 / $4,466.84
| Facility | | $1,778.28 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $194.98 / $234.42
| Professional | | $177.83 | $194.98 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $1,698.24 / $2,137.96
| Professional | | $141.25 | $1,698.24 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Facility | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $269.15 / $323.59
| Professional | | $229.09 | $269.15 | $323.59 |