- 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
- $89.13 / $131.83 / $316.23
| Professional | | $89.13 | $131.83 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $144.54 / $229.09
| Professional | | $93.33 | $144.54 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $131.83 / $208.93
| Professional | | $91.20 | $131.83 | $208.93 |