- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.58 / $170.05 / $267.30
| Professional | | $165.58 | $170.05 | $267.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $274.43 / $457.00 / $532.48
| Facility | | $274.43 | $457.00 | $532.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.08 / $133.28 / $133.28
| Professional | | $84.08 | $133.28 | $133.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $273.85 / $654.17 / $1,150.01
| Facility | | $273.85 | $654.17 | $1,150.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.91 / $146.25 / $213.68
| Professional | | $106.91 | $146.25 | $213.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.71 / $288.44 / $504.77
| Professional | | $88.71 | $288.44 | $504.77 |