- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.59 / $194.35 / $225.65
| Professional | | $169.59 | $194.35 | $225.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.58 / $303.58 / $505.60
| Professional | | $303.58 | $303.58 | $505.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,454.79 / $1,454.79 / $2,588.83
| Facility | | $1,454.79 | $1,454.79 | $2,588.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.18 / $394.86 / $731.88
| Professional | | $222.18 | $394.86 | $731.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.22 / $305.49 / $637.11
| Professional | | $223.22 | $305.49 | $637.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $2,750.00 / $3,500.00
| Professional | | $2,500.00 | $2,750.00 | $3,500.00 |