- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20,417.38 / $20,417.38 / $20,417.38
| Facility | | $20,417.38 | $20,417.38 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $851.14
| Professional | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.08 / $7.08 / $7.08
| Professional | | $7.08 | $7.08 | $7.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.03 / $3,388.44 / $6,760.83
| Facility | | $123.03 | $3,388.44 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $302.00 / $446.68
| Professional | | $263.03 | $302.00 | $446.68 |