- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.61 / $96.65 / $130.19
| Professional | | $46.61 | $96.65 | $130.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,936.20 / $1,936.20 / $2,162.32
| Facility | | $1,936.20 | $1,936.20 | $2,162.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.02 / $246.02 / $246.02
| Professional | | $246.02 | $246.02 | $246.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.26 / $120.26 / $236.29
| Professional | | $66.26 | $120.26 | $236.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.00 / $121.66 / $236.29
| Professional | | $67.00 | $121.66 | $236.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.57 / $213.00 / $431.45
| Professional | | $140.57 | $213.00 | $431.45 |