- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,310.03 / $17,310.03 / $17,310.03
| Facility | | $17,310.03 | $17,310.03 | $17,310.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.28 / $36.28 / $41.72
| Professional | | $36.28 | $36.28 | $41.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.21 / $37.21 / $37.21
| Facility | | $37.21 | $37.21 | $37.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.28 / $36.28 / $36.28
| Professional | | $36.28 | $36.28 | $36.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $34.67 / $34.67
| Facility | | $34.67 | $34.67 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.28 / $38.46 / $46.44
| Professional | | $36.28 | $38.46 | $46.44 |