- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $407.38 / $724.44
| Professional | | $371.54 | $407.38 | $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
- $954.99 / $1,445.44 / $1,445.44
| Professional | | $954.99 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $741.31 / $1,174.90
| Professional | | $436.52 | $741.31 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,630.27 / $10,471.29
| Facility | | $1,380.38 | $2,630.27 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $724.44 / $1,513.56
| Professional | | $398.11 | $724.44 | $1,513.56 |