- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.23 / $126.37 / $240.66
| Professional | | $76.23 | $126.37 | $240.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,178.26 / $1,178.26 / $1,272.93
| Facility | | $1,178.26 | $1,178.26 | $1,272.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.77 / $379.29 / $700.19
| Professional | | $321.77 | $379.29 | $700.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.73 / $205.94 / $502.60
| Professional | | $107.73 | $205.94 | $502.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.78 / $243.50 / $494.24
| Professional | | $112.78 | $243.50 | $494.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.27 / $315.00 / $859.41
| Professional | | $204.27 | $315.00 | $859.41 |