- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.09 / $96.15 / $267.89
| Professional | | $69.09 | $96.15 | $267.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,176.13 / $2,176.13 / $2,430.26
| Facility | | $2,176.13 | $2,176.13 | $2,430.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.56 / $187.66 / $488.50
| Professional | | $104.56 | $187.66 | $488.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.56 / $246.44 / $488.50
| Professional | | $104.56 | $246.44 | $488.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.03 / $306.82 / $891.96
| Professional | | $252.03 | $306.82 | $891.96 |