- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.40 / $87.30 / $366.93
| Professional | | $79.40 | $87.30 | $366.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $421.77 / $843.05 / $1,032.81
| Facility | | $421.77 | $843.05 | $1,032.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.31 / $83.41 / $250.89
| Professional | | $72.31 | $83.41 | $250.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.31 / $82.13 / $250.89
| Professional | | $72.31 | $82.13 | $250.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.01 / $97.93 / $307.94
| Professional | | $82.01 | $97.93 | $307.94 |