- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $134.90 / $562.34
| Professional | | $95.50 | $134.90 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $269.15 / $501.19
| Professional | | $173.78 | $269.15 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.09 / $229.09 / $229.09
| Facility | | $229.09 | $229.09 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $199.53 / $288.40
| Professional | | $79.43 | $199.53 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $257.04 / $338.84
| Professional | | $147.91 | $257.04 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $229.09 / $416.87
| Professional | | $89.13 | $229.09 | $416.87 |