- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.39 / $104.31 / $452.23
| Professional | | $73.39 | $104.31 | $452.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.71 / $136.71 / $136.71
| Facility | | $136.71 | $136.71 | $136.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.82 / $138.22 / $282.92
| Professional | | $86.82 | $138.22 | $282.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $74.83 / $109.35 / $197.34
| Facility | | $74.83 | $109.35 | $197.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.46 / $185.76 / $295.68
| Professional | | $109.46 | $185.76 | $295.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.50 / $204.17 / $263.95
| Professional | | $159.50 | $204.17 | $263.95 |