- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.48 / $58.48 / $239.44
| Professional | | $58.48 | $58.48 | $239.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,607.20 / $5,607.20 / $5,607.20
| Facility | | $5,607.20 | $5,607.20 | $5,607.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.53 / $75.92 / $94.17
| Professional | | $33.53 | $75.92 | $94.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.41 / $75.92 / $94.17
| Professional | | $64.41 | $75.92 | $94.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.22 / $69.43 / $195.71
| Professional | | $61.22 | $69.43 | $195.71 |