- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.84 / $302.93 / $507.07
| Professional | | $252.84 | $302.93 | $507.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $270.51 / $655.77 / $1,813.36
| Facility | | $270.51 | $655.77 | $1,813.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.00 / $129.00 / $210.00
| Professional | | $81.00 | $129.00 | $210.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.90 / $341.70 / $929.20
| Professional | | $225.90 | $341.70 | $929.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $639.60 / $1,600.36 / $1,600.36
| Facility | | $639.60 | $1,600.36 | $1,600.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,521.23 / $2,521.23 / $2,521.23
| Professional | | $2,521.23 | $2,521.23 | $2,521.23 |