- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.25 / $373.88 / $467.34
| Professional | | $161.25 | $373.88 | $467.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,898.65 / $8,898.65 / $8,898.65
| Facility | | $8,898.65 | $8,898.65 | $8,898.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,025.09 / $2,025.09 / $2,025.09
| Professional | | $2,025.09 | $2,025.09 | $2,025.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $472.25 / $472.25 / $494.37
| Facility | | $472.25 | $472.25 | $494.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $414.95 / $494.37 / $693.06
| Professional | | $414.95 | $494.37 | $693.06 |