- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $194.98 / $251.19
| Professional | | $109.65 | $194.98 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $154.88 / $275.42
| Professional | | $131.83 | $154.88 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $239.88 / $346.74
| Professional | | $158.49 | $239.88 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,548.13 / $7,244.36
| Facility | | $1,659.59 | $3,548.13 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $229.09 / $346.74
| Professional | | $169.82 | $229.09 | $346.74 |