- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,327.86 / $3,327.86 / $3,327.86
| Facility | | $3,327.86 | $3,327.86 | $3,327.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.83 / $261.83 / $701.73
| Professional | | $261.83 | $261.83 | $701.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.35 / $325.35 / $325.35
| Professional | | $325.35 | $325.35 | $325.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.24 / $361.57 / $430.41
| Professional | | $286.24 | $361.57 | $430.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.73 / $371.60 / $624.90
| Professional | | $257.73 | $371.60 | $624.90 |