- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,383.39 / $5,383.39 / $5,383.39
| Facility | | $5,383.39 | $5,383.39 | $5,383.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.54 / $206.72 / $487.14
| Professional | | $163.54 | $206.72 | $487.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.77 / $130.77 / $149.47
| Professional | | $130.77 | $130.77 | $149.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,878.81 / $4,878.81 / $4,878.81
| Facility | | $4,878.81 | $4,878.81 | $4,878.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.73 / $333.66 / $394.09
| Professional | | $262.73 | $333.66 | $394.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.60 / $215.85 / $376.85
| Professional | | $150.60 | $215.85 | $376.85 |