- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $354.81 / $602.56
| Professional | | $316.23 | $354.81 | $602.56 |
- 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
- $691.83 / $1,047.13 / $1,096.48
| Professional | | $691.83 | $1,047.13 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $630.96 / $1,047.13
| Professional | | $380.19 | $630.96 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,380.38 / $3,235.94
| Facility | | $794.33 | $1,380.38 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $630.96 / $1,258.93
| Professional | | $363.08 | $630.96 | $1,258.93 |