- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.91 / $187.62 / $195.95
| Professional | | $172.91 | $187.62 | $195.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $373.38 / $373.38 / $373.38
| Facility | | $373.38 | $373.38 | $373.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.37 / $317.37 / $317.37
| Professional | | $317.37 | $317.37 | $317.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,618.69 / $2,618.69 / $2,618.69
| Facility | | $2,618.69 | $2,618.69 | $2,618.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.25 / $221.02 / $320.74
| Professional | | $189.25 | $221.02 | $320.74 |