- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.65 / $261.83 / $478.32
| Professional | | $129.65 | $261.83 | $478.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,005.10 / $12,005.10 / $15,374.96
| Facility | | $12,005.10 | $12,005.10 | $15,374.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $566.49 / $667.77 / $1,318.26
| Professional | | $566.49 | $667.77 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.25 / $352.90 / $843.10
| Professional | | $195.25 | $352.90 | $843.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.05 / $499.64 / $843.10
| Professional | | $203.05 | $499.64 | $843.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $497.10 / $529.54 / $1,539.40
| Professional | | $497.10 | $529.54 | $1,539.40 |