- 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
- $141.25 / $169.82 / $223.87
| Professional | | $141.25 | $169.82 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.50 / $25.70 / $32.36
| Professional | | $19.50 | $25.70 | $32.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $371.54 / $512.86
| Professional | | $34.67 | $371.54 | $512.86 |