- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.47 / $394.32 / $484.70
| Professional | | $228.47 | $394.32 | $484.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.97 / $520.62 / $520.62
| Professional | | $354.97 | $520.62 | $520.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.23 / $213.23 / $213.23
| Professional | | $213.23 | $213.23 | $213.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $751.16 / $2,372.57 / $2,460.69
| Facility | | $751.16 | $2,372.57 | $2,460.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,931.93 / $2,931.93 / $3,331.73
| Professional | | $2,931.93 | $2,931.93 | $3,331.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.75 / $213.19 / $250.22
| Professional | | $147.75 | $213.19 | $250.22 |