- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.54 / $239.11 / $304.20
| Professional | | $162.54 | $239.11 | $304.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.47 / $153.47 / $153.47
| Professional | | $153.47 | $153.47 | $153.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.70 / $394.70 / $394.70
| Professional | | $394.70 | $394.70 | $394.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.40 / $193.40 / $258.98
| Facility | | $193.40 | $193.40 | $258.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.77 / $193.40 / $326.25
| Professional | | $23.77 | $193.40 | $326.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.40 / $30.18 / $292.50
| Professional | | $11.40 | $30.18 | $292.50 |