- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,036.03 / $4,036.03 / $4,036.03
| Facility | | $4,036.03 | $4,036.03 | $4,036.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.65 / $34.65 / $34.65
| Professional | | $34.65 | $34.65 | $34.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.40 / $125.40 / $125.40
| Professional | | $125.40 | $125.40 | $125.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,913.56 / $3,913.56 / $9,460.06
| Facility | | $3,913.56 | $3,913.56 | $9,460.06 |