- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $107.15 / $199.53
| Professional | | $72.44 | $107.15 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $208.93 / $281.84
| Professional | | $144.54 | $208.93 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $134.90 / $281.84
| Professional | | $91.20 | $134.90 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $295.12 / $3,090.30
| Facility | | $295.12 | $295.12 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $181.97 / $309.03
| Professional | | $97.72 | $181.97 | $309.03 |