- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $147.91 / $162.18
| Professional | | $147.91 | $147.91 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $72.44 / $74.13 / $338.84
| Facility | | $72.44 | $74.13 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,258.93 / $3,090.30
| Facility | | $501.19 | $1,258.93 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $6,918.31
| Professional | | $6,918.31 | $6,918.31 | $6,918.31 |