- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,623.84 / $6,623.84 / $6,623.84
| Facility | | $6,623.84 | $6,623.84 | $6,623.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.42 / $136.82 / $1,844.67
| Professional | | $114.42 | $136.82 | $1,844.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.26 / $143.26 / $143.26
| Facility | | $143.26 | $143.26 | $143.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.26 / $143.26 / $143.26
| Professional | | $143.26 | $143.26 | $143.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,170.19 / $2,170.19 / $2,170.19
| Professional | | $2,170.19 | $2,170.19 | $2,170.19 |