- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $128.82 / $263.03
| Professional | | $120.23 | $128.82 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $380.19 / $457.09
| Professional | | $251.19 | $380.19 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $245.47 / $363.08
| Professional | | $144.54 | $245.47 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,380.38 / $5,370.32
| Facility | | $1,288.25 | $1,380.38 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $234.42 / $457.09
| Professional | | $138.04 | $234.42 | $457.09 |