- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.63 / $174.63 / $358.85
| Professional | | $137.63 | $174.63 | $358.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,721.19 / $2,721.19 / $3,237.01
| Facility | | $2,721.19 | $2,721.19 | $3,237.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.93 / $252.45 / $755.43
| Professional | | $207.93 | $252.45 | $755.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.97 / $205.61 / $520.35
| Professional | | $148.97 | $205.61 | $520.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.31 / $263.83 / $520.35
| Professional | | $186.31 | $263.83 | $520.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.96 / $225.50 / $740.19
| Professional | | $190.96 | $225.50 | $740.19 |