- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.21 / $407.21 / $1,812.01
| Facility | | $407.21 | $407.21 | $1,812.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.58 / $145.58 / $158.44
| Professional | | $145.58 | $145.58 | $158.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.26 / $143.26 / $143.26
| Professional | | $143.26 | $143.26 | $143.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $634.48 / $634.48 / $634.48
| Facility | | $634.48 | $634.48 | $634.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,844.67 / $2,170.19 / $4,774.43
| Professional | | $1,844.67 | $2,170.19 | $4,774.43 |