- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $281.84 / $512.86
| Professional | | $151.36 | $281.84 | $512.86 |
- 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
- $380.19 / $575.44 / $891.25
| Professional | | $380.19 | $575.44 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $371.54 / $691.83
| Professional | | $218.78 | $371.54 | $691.83 |
- 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
- $186.21 / $407.38 / $891.25
| Professional | | $186.21 | $407.38 | $891.25 |