- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.13 / $263.66 / $512.80
| Professional | | $210.13 | $263.66 | $512.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,901.28 / $3,027.98 / $3,964.81
| Facility | | $2,901.28 | $3,027.98 | $3,964.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.29 / $562.29 / $562.29
| Professional | | $562.29 | $562.29 | $562.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.16 / $502.22 / $953.03
| Professional | | $253.16 | $502.22 | $953.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.23 / $549.59 / $953.03
| Professional | | $292.23 | $549.59 | $953.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $566.94 / $685.48 / $1,740.13
| Professional | | $566.94 | $685.48 | $1,740.13 |