- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.54 / $112.64 / $121.54
| Professional | | $89.54 | $112.64 | $121.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $289.75 / $391.36 / $463.32
| Facility | | $289.75 | $391.36 | $463.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.81 / $174.20 / $180.13
| Professional | | $165.81 | $174.20 | $180.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $149.11 / $149.11 / $149.11
| Facility | | $149.11 | $149.11 | $149.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.85 / $149.11 / $149.11
| Professional | | $108.85 | $149.11 | $149.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.06 / $109.54 / $170.41
| Professional | | $80.06 | $109.54 | $170.41 |