- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.18 / $330.34 / $412.92
| Professional | | $172.18 | $330.34 | $412.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $220.55 / $220.55 / $2,250.25
| Facility | | $220.55 | $220.55 | $2,250.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.00 / $1,017.00 / $1,017.00
| Professional | | $396.00 | $1,017.00 | $1,017.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.75 / $158.75 / $282.63
| Facility | | $158.75 | $158.75 | $282.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.25 / $251.64 / $292.47
| Professional | | $146.25 | $251.64 | $292.47 |