- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.82 / $192.57 / $223.31
| Professional | | $187.82 | $192.57 | $223.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $258.51 / $457.00 / $532.48
| Facility | | $258.51 | $457.00 | $532.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.88 / $115.88 / $167.38
| Professional | | $115.88 | $115.88 | $167.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.11 / $654.17 / $1,150.01
| Facility | | $253.11 | $654.17 | $1,150.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.03 / $123.04 / $179.31
| Professional | | $73.03 | $123.04 | $179.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.31 / $286.83 / $530.25
| Professional | | $78.31 | $286.83 | $530.25 |