- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.13 / $363.71 / $435.77
| Professional | | $343.13 | $363.71 | $435.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,684.20 / $1,684.20 / $1,684.20
| Facility | | $1,684.20 | $1,684.20 | $1,684.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,239.82 / $3,239.82 / $3,239.82
| Professional | | $3,239.82 | $3,239.82 | $3,239.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $376.44 / $382.67 / $479.17
| Facility | | $376.44 | $382.67 | $479.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.95 / $405.36 / $690.54
| Professional | | $328.95 | $405.36 | $690.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $484.50 / $484.50 / $542.40
| Professional | | $484.50 | $484.50 | $542.40 |