- 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
- $213.80 / $331.13 / $426.58
| Professional | | $213.80 | $331.13 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $295.12 / $416.87
| Professional | | $295.12 | $295.12 | $416.87 |
- 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 / $380.19 / $478.63
| Professional | | $218.78 | $380.19 | $478.63 |