- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $7,244.36
| Facility | | $4,073.80 | $4,073.80 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $114.82 / $281.84
| Professional | | $107.15 | $114.82 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $128.82 / $213.80
| Professional | | $97.72 | $128.82 | $213.80 |
- 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
- $100.00 / $138.04 / $204.17
| Professional | | $100.00 | $138.04 | $204.17 |