- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.68 / $77.56 / $256.79
| Professional | | $48.68 | $77.56 | $256.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,009.19 / $1,009.19 / $1,009.19
| Facility | | $1,009.19 | $1,009.19 | $1,009.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.10 / $70.70 / $106.83
| Professional | | $60.10 | $70.70 | $106.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.26 / $1,278.93 / $2,115.71
| Facility | | $85.26 | $1,278.93 | $2,115.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.98 / $104.68 / $104.68
| Professional | | $88.98 | $104.68 | $104.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.06 / $93.83 / $139.08
| Professional | | $75.06 | $93.83 | $139.08 |