- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.75 / $139.38 / $155.27
| Professional | | $117.75 | $139.38 | $155.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $594.41 / $798.92 / $910.67
| Facility | | $594.41 | $798.92 | $910.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.65 / $149.65 / $317.27
| Professional | | $149.65 | $149.65 | $317.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.41 / $964.52 / $1,695.57
| Facility | | $478.41 | $964.52 | $1,695.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.88 / $260.19 / $334.17
| Professional | | $155.88 | $260.19 | $334.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.66 / $151.26 / $264.89
| Professional | | $94.66 | $151.26 | $264.89 |