- 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
- $257.04 / $316.23 / $660.69
| Professional | | $257.04 | $316.23 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $363.08 / $489.78
| Professional | | $269.15 | $363.08 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Facility | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $331.13 / $501.19
| Professional | | $251.19 | $331.13 | $501.19 |