- 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
- $169.82 / $213.80 / $457.09
| Professional | | $169.82 | $213.80 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $208.93 / $263.03
| Professional | | $177.83 | $208.93 | $263.03 |
- 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
- $147.91 / $199.53 / $436.52
| Professional | | $147.91 | $199.53 | $436.52 |