- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $158.49 / $234.42
| Professional | | $114.82 | $158.49 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $7,413.10
| Facility | | $3,548.13 | $3,548.13 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $331.13 / $549.54
| Professional | | $186.21 | $331.13 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $549.54
| Professional | | $162.18 | $162.18 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $281.84 / $794.33
| Professional | | $144.54 | $281.84 | $794.33 |