- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.41 / $549.41 / $658.26
| Professional | | $549.41 | $549.41 | $658.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $784.58 / $1,713.46 / $1,803.64
| Facility | | $784.58 | $1,713.46 | $1,803.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,254.55 / $2,254.55 / $2,254.55
| Professional | | $2,254.55 | $2,254.55 | $2,254.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.08 / $545.60 / $1,578.18
| Professional | | $293.08 | $545.60 | $1,578.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $450.91 / $626.76 / $626.76
| Facility | | $450.91 | $626.76 | $626.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $473.46 / $541.09 / $631.27
| Professional | | $473.46 | $541.09 | $631.27 |