- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.36 / $153.82 / $324.25
| Professional | | $110.36 | $153.82 | $324.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.50 / $240.50 / $240.50
| Facility | | $240.50 | $240.50 | $240.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.43 / $240.50 / $386.25
| Professional | | $204.43 | $240.50 | $386.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.86 / $285.86 / $285.86
| Professional | | $285.86 | $285.86 | $285.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.76 / $13.76 / $221.44
| Professional | | $13.76 | $13.76 | $221.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.32 / $191.98 / $296.63
| Professional | | $148.32 | $191.98 | $296.63 |