- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $234.42 / $288.40
| Professional | | $151.36 | $234.42 | $288.40 |
- 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
- $371.54 / $562.34 / $741.31
| Professional | | $371.54 | $562.34 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $354.81 / $691.83
| Professional | | $223.87 | $354.81 | $691.83 |
- 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
- $190.55 / $380.19 / $776.25
| Professional | | $190.55 | $380.19 | $776.25 |