- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.37 / $130.19 / $403.91
| Professional | | $55.37 | $130.19 | $403.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,021.54 / $1,021.54 / $1,308.29
| Facility | | $1,021.54 | $1,021.54 | $1,308.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.11 / $603.33 / $603.33
| Professional | | $387.11 | $603.33 | $603.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.54 / $187.41 / $477.88
| Professional | | $95.54 | $187.41 | $477.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.84 / $234.86 / $462.32
| Professional | | $107.84 | $234.86 | $462.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.65 / $295.66 / $442.05
| Professional | | $191.65 | $295.66 | $442.05 |