- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.65 / $79.72 / $106.48
| Professional | | $74.65 | $79.72 | $106.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.62 / $330.89 / $429.02
| Facility | | $288.62 | $330.89 | $429.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.86 / $128.07 / $171.73
| Professional | | $108.86 | $128.07 | $171.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.30 / $120.30 / $120.30
| Facility | | $120.30 | $120.30 | $120.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.26 / $120.30 / $120.30
| Professional | | $102.26 | $120.30 | $120.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.76 / $122.36 / $177.35
| Professional | | $77.76 | $122.36 | $177.35 |