- 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
- $56.23 / $104.71 / $223.87
| Professional | | $56.23 | $104.71 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $87.10 / $138.04
| Professional | | $56.23 | $87.10 | $138.04 |
- 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
- $57.54 / $83.18 / $134.90
| Professional | | $57.54 | $83.18 | $134.90 |