- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Facility | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $213.80 / $234.42
| Professional | | $173.78 | $213.80 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.49 / $17.78 / $21.88
| Professional | | $15.49 | $17.78 | $21.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $389.05 / $478.63
| Professional | | $218.78 | $389.05 | $478.63 |