- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.65 / $123.31 / $139.19
| Professional | | $103.65 | $123.31 | $139.19 |
- 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
- $131.58 / $131.58 / $252.87
| Professional | | $131.58 | $131.58 | $252.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $412.47 / $964.52 / $1,695.57
| Facility | | $412.47 | $964.52 | $1,695.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.06 / $231.05 / $280.22
| Professional | | $137.06 | $231.05 | $280.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.06 / $159.46 / $196.55
| Professional | | $84.06 | $159.46 | $196.55 |