- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $7,244.36
| Facility | | $3,235.94 | $3,235.94 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $194.98 / $457.09
| Professional | | $162.18 | $194.98 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $208.93 / $346.74
| Professional | | $151.36 | $208.93 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $144.54 / $501.19
| Facility | | $144.54 | $144.54 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $194.98 / $316.23
| Professional | | $154.88 | $194.98 | $316.23 |