- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $478.63 / $691.83
| Professional | | $354.81 | $478.63 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $741.31 / $1,949.84
| Facility | | $537.03 | $741.31 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,548.82 / $1,548.82
| Professional | | $1,318.26 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $741.31 / $1,230.27
| Facility | | $478.63 | $741.31 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $489.78 / $741.31
| Professional | | $380.19 | $489.78 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,398.83 / $4,265.80
| Professional | | $1,174.90 | $2,398.83 | $4,265.80 |