- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.57 / $111.66 / $166.12
| Facility | | $104.57 | $111.66 | $166.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.21 / $104.50 / $132.51
| Professional | | $93.21 | $104.50 | $132.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $685.50 / $1,166.15 / $3,483.70
| Facility | | $685.50 | $1,166.15 | $3,483.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.01 / $148.29 / $211.22
| Professional | | $121.01 | $148.29 | $211.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.51 / $190.33 / $190.33
| Professional | | $150.51 | $190.33 | $190.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.00 / $152.00 / $224.00
| Professional | | $133.00 | $152.00 | $224.00 |