- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.99 / $82.76 / $82.76
| Professional | | $52.99 | $82.76 | $82.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $405.28 / $1,151.29 / $1,279.21
| Facility | | $405.28 | $1,151.29 | $1,279.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.44 / $105.44 / $105.44
| Professional | | $105.44 | $105.44 | $105.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.95 / $1,432.33 / $2,517.94
| Facility | | $436.95 | $1,432.33 | $2,517.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.80 / $147.56 / $210.58
| Professional | | $75.80 | $147.56 | $210.58 |