- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.79 / $138.04 / $501.19
| Professional | | $70.79 | $138.04 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,862.09
| Facility | | $1,698.24 | $1,698.24 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $128.82 / $208.93
| Professional | | $87.10 | $128.82 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $190.55 / $245.47
| Professional | | $144.54 | $190.55 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $181.97 / $338.84
| Professional | | $87.10 | $181.97 | $338.84 |