- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $5,623.41
| Facility | | $5,623.41 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $204.17 / $239.88
| Professional | | $107.15 | $204.17 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $478.63 / $478.63
| Facility | | $478.63 | $478.63 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $407.38 / $478.63
| Professional | | $346.74 | $407.38 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $199.53 / $234.42
| Facility | | $190.55 | $199.53 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $199.53 / $389.05
| Professional | | $147.91 | $199.53 | $389.05 |