- 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
- $229.09 / $251.19 / $602.56
| Professional | | $229.09 | $251.19 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $269.15 / $457.09
| Professional | | $213.80 | $269.15 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $144.54 / $501.19
| Facility | | $144.54 | $144.54 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $295.12 / $436.52
| Professional | | $213.80 | $295.12 | $436.52 |