- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.82 / $97.33 / $232.17
| Professional | | $61.82 | $97.33 | $232.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,213.57 / $1,492.28 / $1,609.87
| Facility | | $1,213.57 | $1,492.28 | $1,609.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $409.35 / $409.35 / $595.89
| Professional | | $409.35 | $409.35 | $595.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.59 / $207.88 / $368.40
| Professional | | $106.59 | $207.88 | $368.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.71 / $223.71 / $368.40
| Professional | | $113.71 | $223.71 | $368.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.11 / $243.45 / $672.67
| Professional | | $222.11 | $243.45 | $672.67 |