- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.10 / $41.74 / $103.45
| Professional | | $30.10 | $41.74 | $103.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $62.77 / $249.27 / $410.66
| Facility | | $62.77 | $249.27 | $410.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.08 / $94.94 / $118.68
| Professional | | $83.08 | $94.94 | $118.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $189.46 / $236.65 / $342.79
| Facility | | $189.46 | $236.65 | $342.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.22 / $78.13 / $148.77
| Professional | | $54.22 | $78.13 | $148.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.34 / $143.80 / $422.94
| Facility | | $80.34 | $143.80 | $422.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $620.54 / $620.54 / $620.54
| Professional | | $620.54 | $620.54 | $620.54 |