- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37,389.15 / $37,389.15 / $37,389.15
| Facility | | $37,389.15 | $37,389.15 | $37,389.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.25 / $164.25 / $197.48
| Professional | | $164.25 | $164.25 | $197.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $160.13 / $160.13 / $160.13
| Facility | | $160.13 | $160.13 | $160.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.25 / $164.25 / $164.25
| Professional | | $164.25 | $164.25 | $164.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.04 / $174.11 / $210.24
| Professional | | $156.04 | $174.11 | $210.24 |