- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $3,981.07
| Facility | | $977.24 | $977.24 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $190.55 / $489.78
| Professional | | $109.65 | $190.55 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $165.96 / $257.04
| Professional | | $107.15 | $165.96 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $234.42 / $338.84
| Professional | | $141.25 | $234.42 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,454.71 / $6,025.60
| Facility | | $1,380.38 | $2,454.71 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $186.21 / $323.59
| Professional | | $117.49 | $186.21 | $323.59 |