- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.79 / $111.82 / $133.47
| Professional | | $88.79 | $111.82 | $133.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.48 / $302.99 / $361.31
| Facility | | $208.48 | $302.99 | $361.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.98 / $124.68 / $164.91
| Professional | | $105.98 | $124.68 | $164.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.81 / $141.06 / $221.46
| Professional | | $131.81 | $141.06 | $221.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.68 / $142.80 / $187.25
| Professional | | $113.68 | $142.80 | $187.25 |