- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.43 / $141.97 / $597.00
| Professional | | $82.43 | $141.97 | $597.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $681.34 / $681.34 / $872.60
| Facility | | $681.34 | $681.34 | $872.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.67 / $247.15 / $683.81
| Professional | | $209.67 | $247.15 | $683.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.43 / $194.14 / $683.81
| Professional | | $124.43 | $194.14 | $683.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.46 / $207.75 / $683.81
| Professional | | $152.46 | $207.75 | $683.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.74 / $221.69 / $839.30
| Professional | | $165.74 | $221.69 | $839.30 |