- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $363.08 / $645.65
| Professional | | $316.23 | $363.08 | $645.65 |
- 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
- $851.14 / $1,288.25 / $1,288.25
| Professional | | $851.14 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $630.96 / $1,047.13
| Professional | | $363.08 | $630.96 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $1,380.38 / $3,090.30
| Facility | | $295.12 | $1,380.38 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $602.56 / $1,288.25
| Professional | | $354.81 | $602.56 | $1,288.25 |