- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,120.10 / $5,120.10 / $5,120.10
| Facility | | $5,120.10 | $5,120.10 | $5,120.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,120.10 / $5,120.10 / $5,120.10
| Professional | | $5,120.10 | $5,120.10 | $5,120.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.47 / $327.16 / $809.07
| Facility | | $138.47 | $327.16 | $809.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.63 / $173.10 / $408.94
| Professional | | $140.63 | $173.10 | $408.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,120.10 / $5,632.12 / $10,833.95
| Facility | | $5,120.10 | $5,632.12 | $10,833.95 |