- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.52 / $87.57 / $169.99
| Professional | | $61.52 | $87.57 | $169.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,145.46 / $2,145.46 / $2,317.86
| Facility | | $2,145.46 | $2,145.46 | $2,317.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.47 / $151.02 / $315.74
| Professional | | $95.47 | $151.02 | $315.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.47 / $166.64 / $315.74
| Professional | | $95.47 | $166.64 | $315.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.83 / $198.31 / $576.50
| Professional | | $183.83 | $198.31 | $576.50 |