- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.31 / $159.31 / $175.24
| Professional | | $159.31 | $159.31 | $175.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $241.47 / $693.40 / $866.52
| Facility | | $241.47 | $693.40 | $866.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.21 / $269.88 / $385.54
| Professional | | $20.21 | $269.88 | $385.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.68 / $195.68 / $195.68
| Facility | | $195.68 | $195.68 | $195.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.88 / $46.31 / $690.93
| Professional | | $23.88 | $46.31 | $690.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.36 / $257.14 / $488.39
| Professional | | $67.36 | $257.14 | $488.39 |