- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.28 / $148.49 / $191.71
| Professional | | $121.28 | $148.49 | $191.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.10 / $616.42 / $1,080.14
| Facility | | $165.10 | $616.42 | $1,080.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.28 / $129.46 / $160.99
| Professional | | $91.28 | $129.46 | $160.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.06 / $141.06 / $141.06
| Professional | | $141.06 | $141.06 | $141.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.28 / $151.15 / $281.94
| Facility | | $121.28 | $151.15 | $281.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.65 / $202.39 / $1,105.55
| Professional | | $159.65 | $202.39 | $1,105.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.34 / $190.18 / $344.38
| Professional | | $159.34 | $190.18 | $344.38 |