- 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
- $64.57 / $162.18 / $354.81
| Professional | | $64.57 | $162.18 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $112.20 / $218.78
| Professional | | $58.88 | $112.20 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $141.25
| Professional | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $117.49 / $194.98
| Professional | | $52.48 | $117.49 | $194.98 |