- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,379.35 / $2,379.35 / $2,379.35
| Facility | | $2,379.35 | $2,379.35 | $2,379.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $481.59 / $481.59 / $481.59
| Professional | | $481.59 | $481.59 | $481.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $237.46 / $237.46 / $237.46
| Facility | | $237.46 | $237.46 | $237.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.64 / $190.76 / $273.92
| Professional | | $109.64 | $190.76 | $273.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.10 / $285.30 / $331.00
| Professional | | $276.10 | $285.30 | $331.00 |