- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.42 / $28.21 / $31.08
| Professional | | $15.42 | $28.21 | $31.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66.38 / $80.62 / $109.05
| Facility | | $66.38 | $80.62 | $109.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.42 / $169.42 / $169.42
| Facility | | $169.42 | $169.42 | $169.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,551.00 / $2,257.00 / $6,383.00
| Facility | | $1,551.00 | $2,257.00 | $6,383.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.16 / $28.58 / $41.38
| Professional | | $22.16 | $28.58 | $41.38 |