- 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
- $77.62 / $91.20 / $199.53
| Professional | | $77.62 | $91.20 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.18 / $117.49 / $141.25
| Professional | | $69.18 | $117.49 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Facility | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $109.65 / $165.96
| Professional | | $79.43 | $109.65 | $165.96 |