- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $173.78 / $575.44
| Professional | | $83.18 | $173.78 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,949.84
| Facility | | $1,778.28 | $1,778.28 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $263.03 / $645.65
| Professional | | $263.03 | $263.03 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $229.09 / $645.65
| Professional | | $120.23 | $229.09 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $234.42 / $436.52
| Professional | | $177.83 | $234.42 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $190.55 / $380.19
| Professional | | $95.50 | $190.55 | $380.19 |