- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.11 / $74.51 / $74.51
| Professional | | $67.11 | $74.51 | $74.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $697.58 / $1,008.08 / $1,174.58
| Facility | | $697.58 | $1,008.08 | $1,174.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.59 / $39.59 / $39.59
| Professional | | $39.59 | $39.59 | $39.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $235.62 / $1,242.66 / $2,184.52
| Facility | | $235.62 | $1,242.66 | $2,184.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.09 / $149.66 / $151.84
| Professional | | $86.09 | $149.66 | $151.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.67 / $112.60 / $150.52
| Professional | | $64.67 | $112.60 | $150.52 |