- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.26 / $138.66 / $138.66
| Professional | | $103.26 | $138.66 | $138.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.39 / $331.92 / $333.58
| Professional | | $261.39 | $331.92 | $333.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.33 / $169.33 / $211.66
| Professional | | $169.33 | $169.33 | $211.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $88.51 / $112.12 / $186.84
| Facility | | $88.51 | $112.12 | $186.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.02 / $404.72 / $1,213.06
| Professional | | $177.02 | $404.72 | $1,213.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.47 / $306.83 / $323.07
| Professional | | $150.47 | $306.83 | $323.07 |