- 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
- $42.66 / $77.62 / $181.97
| Professional | | $42.66 | $77.62 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.77 / $75.86 / $123.03
| Professional | | $46.77 | $75.86 | $123.03 |
- 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
- $48.98 / $72.44 / $112.20
| Professional | | $48.98 | $72.44 | $112.20 |