- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,275.89 / $5,275.89 / $5,275.89
| Facility | | $5,275.89 | $5,275.89 | $5,275.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.46 / $168.46 / $451.47
| Professional | | $168.46 | $168.46 | $451.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.40 / $243.40 / $243.40
| Professional | | $243.40 | $243.40 | $243.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.26 / $235.27 / $280.33
| Professional | | $186.26 | $235.27 | $280.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.25 / $204.89 / $384.66
| Professional | | $161.25 | $204.89 | $384.66 |