- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,059.77 / $3,911.66 / $4,896.45
| Facility | | $1,059.77 | $3,911.66 | $4,896.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.45 / $178.21 / $242.31
| Professional | | $176.45 | $178.21 | $242.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.73 / $542.03 / $542.03
| Professional | | $460.73 | $542.03 | $542.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.46 / $166.46 / $166.46
| Facility | | $166.46 | $166.46 | $166.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.45 / $216.40 / $249.69
| Professional | | $176.45 | $216.40 | $249.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.45 / $176.45 / $176.45
| Professional | | $176.45 | $176.45 | $176.45 |