- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $575.44 / $977.24
| Professional | | $75.86 | $575.44 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $602.56 / $1,995.26
| Professional | | $138.04 | $602.56 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $549.54 / $2,691.53
| Professional | | $173.78 | $549.54 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $1,071.52 / $2,398.83
| Professional | | $173.78 | $1,071.52 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,621.81 / $3,235.94
| Professional | | $870.96 | $1,621.81 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $691.83 / $2,398.83
| Professional | | $117.49 | $691.83 | $2,398.83 |