- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.93 / $420.81 / $579.66
| Professional | | $82.93 | $420.81 | $579.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.61 / $124.61 / $124.61
| Facility | | $124.61 | $124.61 | $124.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.20 / $133.86 / $198.23
| Professional | | $108.20 | $133.86 | $198.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $76.48 / $165.10 / $174.57
| Facility | | $76.48 | $165.10 | $174.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.37 / $133.88 / $205.97
| Professional | | $82.37 | $133.88 | $205.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.66 / $183.85 / $351.50
| Professional | | $144.66 | $183.85 | $351.50 |