- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.90 / $258.38 / $516.34
| Professional | | $205.90 | $258.38 | $516.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,207.26 / $3,368.39 / $4,601.50
| Facility | | $3,207.26 | $3,368.39 | $4,601.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $552.64 / $552.64 / $552.64
| Professional | | $552.64 | $552.64 | $552.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.37 / $492.21 / $943.21
| Professional | | $253.37 | $492.21 | $943.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.27 / $543.76 / $943.21
| Professional | | $288.27 | $543.76 | $943.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.11 / $692.97 / $1,722.22
| Professional | | $561.11 | $692.97 | $1,722.22 |