- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.37 / $149.93 / $445.16
| Professional | | $78.37 | $149.93 | $445.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,236.86 / $2,236.86 / $2,416.59
| Facility | | $2,236.86 | $2,236.86 | $2,416.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.61 / $260.61 / $640.79
| Professional | | $260.61 | $260.61 | $640.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.43 / $192.00 / $640.79
| Professional | | $119.43 | $192.00 | $640.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.77 / $229.66 / $640.79
| Professional | | $130.77 | $229.66 | $640.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.73 / $244.02 / $786.51
| Professional | | $191.73 | $244.02 | $786.51 |