- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.64 / $91.47 / $103.78
| Professional | | $80.64 | $91.47 | $103.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $809.62 / $899.58 / $1,189.96
| Facility | | $809.62 | $899.58 | $1,189.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.02
| Professional | | $0.02 | $0.02 | $0.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.68 / $104.68 / $104.68
| Professional | | $104.68 | $104.68 | $104.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.87 / $107.24 / $155.97
| Professional | | $82.87 | $107.24 | $155.97 |