- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.34 / $103.59 / $111.77
| Professional | | $82.34 | $103.59 | $111.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $266.44 / $359.86 / $426.03
| Facility | | $266.44 | $359.86 | $426.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.46 / $160.18 / $165.63
| Professional | | $152.46 | $160.18 | $165.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.78 / $107.78 / $107.78
| Facility | | $107.78 | $107.78 | $107.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.68 / $107.78 / $107.78
| Professional | | $78.68 | $107.78 | $107.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.28 / $85.28 / $85.28
| Facility | | $85.28 | $85.28 | $85.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.75 / $94.01 / $156.69
| Professional | | $64.75 | $94.01 | $156.69 |