- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.13 / $266.27 / $379.76
| Professional | | $210.13 | $266.27 | $379.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,449.72 / $1,449.72 / $1,449.72
| Professional | | $1,449.72 | $1,449.72 | $1,449.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.39 / $318.39 / $477.60
| Facility | | $318.39 | $318.39 | $477.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.64 / $270.64 / $270.64
| Professional | | $270.64 | $270.64 | $270.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.17 / $27.26 / $51.63
| Professional | | $23.17 | $27.26 | $51.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.63 / $51.63 / $300.39
| Professional | | $51.63 | $51.63 | $300.39 |