- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,344.23
| Facility | | $2,238.72 | $2,238.72 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $223.87 / $407.38
| Professional | | $138.04 | $223.87 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $380.19 / $426.58
| Professional | | $309.03 | $380.19 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $223.87 / $380.19
| Professional | | $190.55 | $223.87 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $794.33 / $3,235.94
| Facility | | $524.81 | $794.33 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $302.00 / $549.54
| Professional | | $194.98 | $302.00 | $549.54 |