- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.87 / $63.55 / $74.26
| Professional | | $51.87 | $63.55 | $74.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $221.87 / $1,011.12 / $2,109.55
| Facility | | $221.87 | $1,011.12 | $2,109.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119,998.80 / $119,998.80 / $119,998.80
| Professional | | $119,998.80 | $119,998.80 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $74.56 / $74.56 / $74.56
| Facility | | $74.56 | $74.56 | $74.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.81 / $311.81 / $311.81
| Professional | | $311.81 | $311.81 | $311.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.48 / $59.44 / $113.11
| Professional | | $46.48 | $59.44 | $113.11 |