- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.25 / $609.77 / $730.57
| Professional | | $575.25 | $609.77 | $730.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.00 / $2,074.00 / $2,074.00
| Facility | | $85.00 | $2,074.00 | $2,074.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.85 / $522.27 / $522.27
| Professional | | $19.85 | $522.27 | $522.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.13 / $19.85 / $19.85
| Professional | | $19.13 | $19.85 | $19.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.70 / $11.70 / $11.70
| Professional | | $11.70 | $11.70 | $11.70 |