- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.64 / $110.26 / $137.56
| Professional | | $58.64 | $110.26 | $137.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,711.55 / $1,711.55 / $1,849.07
| Facility | | $1,711.55 | $1,711.55 | $1,849.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.38 / $219.70 / $492.97
| Professional | | $186.38 | $219.70 | $492.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.33 / $139.93 / $256.45
| Professional | | $83.33 | $139.93 | $256.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.87 / $149.88 / $256.45
| Professional | | $84.87 | $149.88 | $256.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.57 / $185.70 / $468.28
| Professional | | $152.57 | $185.70 | $468.28 |