- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.82 / $2,252.35 / $3,096.93
| Facility | | $161.82 | $2,252.35 | $3,096.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.07 / $161.82 / $161.82
| Professional | | $104.07 | $161.82 | $161.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,225.10 / $1,225.10 / $1,225.10
| Professional | | $1,225.10 | $1,225.10 | $1,225.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.26 / $143.26 / $143.26
| Facility | | $143.26 | $143.26 | $143.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.26 / $143.26 / $143.26
| Professional | | $143.26 | $143.26 | $143.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.17 / $174.17 / $220.97
| Professional | | $174.17 | $174.17 | $220.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,170.19 / $2,170.19 / $3,517.42
| Professional | | $2,170.19 | $2,170.19 | $3,517.42 |