- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.29 / $159.47 / $312.37
| Professional | | $120.29 | $159.47 | $312.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,145.02 / $2,145.02 / $2,747.12
| Facility | | $2,145.02 | $2,145.02 | $2,747.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.58 / $213.42 / $649.33
| Professional | | $175.58 | $213.42 | $649.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.99 / $224.06 / $604.60
| Professional | | $162.99 | $224.06 | $604.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.58 / $246.89 / $604.60
| Professional | | $172.58 | $246.89 | $604.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.51 / $205.69 / $702.46
| Professional | | $175.51 | $205.69 | $702.46 |