- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.34 / $102.08 / $133.68
| Professional | | $57.34 | $102.08 | $133.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $556.02 / $1,193.75 / $1,345.80
| Facility | | $556.02 | $1,193.75 | $1,345.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.12 / $145.12 / $425.37
| Professional | | $123.12 | $145.12 | $425.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.84 / $120.27 / $201.36
| Professional | | $80.84 | $120.27 | $201.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.77 / $130.94 / $201.36
| Professional | | $82.77 | $130.94 | $201.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.59 / $126.48 / $367.67
| Professional | | $93.59 | $126.48 | $367.67 |