- 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
- $104.71 / $147.91 / $269.15
| Professional | | $104.71 | $147.91 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Facility | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $158.49 / $281.84
| Professional | | $102.33 | $158.49 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $144.54 / $501.19
| Facility | | $104.71 | $144.54 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $141.25 / $213.80
| Professional | | $97.72 | $141.25 | $213.80 |