- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $186.21 / $269.15
| Professional | | $134.90 | $186.21 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,412.54
| Facility | | $1,412.54 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $7,413.10
| Facility | | $3,981.07 | $3,981.07 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $371.54 / $616.60
| Professional | | $223.87 | $371.54 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $181.97 / $645.65
| Professional | | $181.97 | $181.97 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $338.84 / $794.33
| Professional | | $169.82 | $338.84 | $794.33 |