- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.36 / $78.62 / $302.35
| Professional | | $62.36 | $78.62 | $302.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,825.07 / $2,825.07 / $3,052.06
| Facility | | $2,825.07 | $2,825.07 | $3,052.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.61 / $258.61 / $258.61
| Professional | | $258.61 | $258.61 | $258.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.25 / $187.81 / $428.04
| Professional | | $87.25 | $187.81 | $428.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.03 / $248.30 / $428.04
| Professional | | $88.03 | $248.30 | $428.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.63 / $314.58 / $781.54
| Professional | | $254.63 | $314.58 | $781.54 |