- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $7,244.36
| Facility | | $7,244.36 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $117.49 / $275.42
| Professional | | $57.54 | $117.49 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $102.33 / $199.53
| Professional | | $57.54 | $102.33 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Facility | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $93.33 / $162.18
| Professional | | $52.48 | $93.33 | $162.18 |