- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.07 / $136.34 / $287.29
| Professional | | $109.07 | $136.34 | $287.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $94.85 / $220.13 / $605.61
| Facility | | $94.85 | $220.13 | $605.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.00 / $1,397.77 / $1,397.77
| Professional | | $194.00 | $1,397.77 | $1,397.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.00 / $204.00 / $204.00
| Facility | | $204.00 | $204.00 | $204.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.66 / $199.00 / $210.00
| Professional | | $112.66 | $199.00 | $210.00 |