- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.56 / $149.56 / $309.04
| Professional | | $114.56 | $149.56 | $309.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,384.37 / $2,384.37 / $2,644.45
| Facility | | $2,384.37 | $2,384.37 | $2,644.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.44 / $459.06 / $970.73
| Professional | | $389.44 | $459.06 | $970.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.44 / $276.35 / $579.67
| Professional | | $170.44 | $276.35 | $579.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.44 / $296.69 / $579.67
| Professional | | $170.44 | $296.69 | $579.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.84 / $445.37 / $1,058.42
| Professional | | $344.84 | $445.37 | $1,058.42 |