- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.16 / $240.16 / $267.68
| Professional | | $123.16 | $240.16 | $267.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.20 / $330.30 / $330.30
| Professional | | $225.20 | $330.30 | $330.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.94 / $114.94 / $114.94
| Professional | | $114.94 | $114.94 | $114.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $462.96 / $1,285.08 / $1,516.58
| Facility | | $462.96 | $1,285.08 | $1,516.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,580.44 / $1,580.44 / $1,795.95
| Professional | | $1,580.44 | $1,580.44 | $1,795.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.64 / $119.47 / $158.75
| Professional | | $79.64 | $119.47 | $158.75 |