- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.70 / $141.72 / $568.00
| Professional | | $74.70 | $141.72 | $568.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.23 / $413.47 / $595.74
| Facility | | $389.23 | $413.47 | $595.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.81 / $194.28 / $475.56
| Professional | | $164.81 | $194.28 | $475.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.53 / $149.35 / $475.56
| Professional | | $97.53 | $149.35 | $475.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.09 / $170.61 / $475.56
| Professional | | $101.09 | $170.61 | $475.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.61 / $174.78 / $583.70
| Professional | | $148.61 | $174.78 | $583.70 |