- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $416.87 / $724.44
| Professional | | $371.54 | $416.87 | $724.44 |
- 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
- $794.33 / $1,202.26 / $1,318.26
| Professional | | $794.33 | $1,202.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $758.58 / $1,288.25
| Professional | | $436.52 | $758.58 | $1,288.25 |
- 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
- $416.87 / $758.58 / $1,445.44
| Professional | | $416.87 | $758.58 | $1,445.44 |