- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.40 / $122.09 / $520.00
| Professional | | $40.40 | $122.09 | $520.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $579.82 / $910.85 / $1,017.23
| Facility | | $579.82 | $910.85 | $1,017.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.38 / $146.38 / $373.16
| Professional | | $146.38 | $146.38 | $373.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.15 / $156.18 / $373.16
| Professional | | $60.15 | $156.18 | $373.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.43 / $168.48 / $373.16
| Professional | | $71.43 | $168.48 | $373.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.31 / $155.68 / $458.01
| Professional | | $142.31 | $155.68 | $458.01 |