- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $199.53 / $245.47
| Professional | | $134.90 | $199.53 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.49 / $117.49 / $489.78
| Facility | | $117.49 | $117.49 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $436.52 / $436.52
| Professional | | $91.20 | $436.52 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $120.23
| Professional | | $109.65 | $109.65 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $208.93 / $239.88
| Professional | | $112.20 | $208.93 | $239.88 |