- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.64 / $116.54 / $149.59
| Professional | | $110.64 | $116.54 | $149.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.51 / $88.51 / $102.44
| Professional | | $88.51 | $88.51 | $102.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.45 / $206.53 / $399.48
| Professional | | $105.45 | $206.53 | $399.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.58 / $102.12 / $351.78
| Facility | | $95.58 | $102.12 | $351.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.26 / $101.47 / $341.78
| Professional | | $67.26 | $101.47 | $341.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $256.68 / $1,039.28 / $1,039.28
| Facility | | $256.68 | $1,039.28 | $1,039.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,106.40 / $1,213.06 / $1,213.06
| Professional | | $1,106.40 | $1,213.06 | $1,213.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.51 / $147.52 / $344.73
| Professional | | $88.51 | $147.52 | $344.73 |