- 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
- $123.03 / $158.49 / $389.05
| Professional | | $123.03 | $158.49 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $186.21 / $245.47
| Professional | | $147.91 | $186.21 | $245.47 |
- 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
- $120.23 / $169.82 / $281.84
| Professional | | $120.23 | $169.82 | $281.84 |