- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $186.21 / $489.78
| Professional | | $120.23 | $186.21 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $1,737.80
| Facility | | $1,584.89 | $1,584.89 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $199.53 / $281.84
| Professional | | $134.90 | $199.53 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $263.03 / $323.59
| Professional | | $199.53 | $263.03 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $234.42 / $446.68
| Professional | | $151.36 | $234.42 | $446.68 |