- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.20 / $437.74 / $5,463.97
| Professional | | $65.20 | $437.74 | $5,463.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.55 / $133.55 / $133.55
| Facility | | $133.55 | $133.55 | $133.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.42 / $437.81 / $4,437.75
| Professional | | $83.42 | $437.81 | $4,437.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $84.48 / $1,611.85 / $3,992.97
| Facility | | $84.48 | $1,611.85 | $3,992.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.56 / $1,915.48 / $4,871.54
| Professional | | $117.56 | $1,915.48 | $4,871.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,716.56 / $3,313.52 / $4,884.91
| Professional | | $2,716.56 | $3,313.52 | $4,884.91 |