- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $630.96 / $660.69
| Professional | | $549.54 | $630.96 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Facility | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,344.23
| Professional | | $1,995.26 | $1,995.26 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $346.74 / $660.69
| Facility | | $34.67 | $346.74 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $537.03 / $794.33
| Professional | | $398.11 | $537.03 | $794.33 |