- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $177.83 / $436.52
| Professional | | $104.71 | $177.83 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $2,187.76
| Facility | | $1,698.24 | $1,698.24 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $208.93 / $616.60
| Professional | | $173.78 | $208.93 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $223.87 / $616.60
| Professional | | $162.18 | $223.87 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $281.84 / $281.84
| Professional | | $181.97 | $281.84 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $194.98 / $398.11
| Professional | | $138.04 | $194.98 | $398.11 |