- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.95 / $101.89 / $114.85
| Professional | | $98.95 | $101.89 | $114.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $148.28 / $148.28 / $148.28
| Facility | | $148.28 | $148.28 | $148.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.44 / $148.28 / $148.28
| Professional | | $133.44 | $148.28 | $148.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61.18 / $88.71 / $148.28
| Facility | | $61.18 | $88.71 | $148.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.85 / $148.28 / $207.88
| Professional | | $103.85 | $148.28 | $207.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.55 / $121.54 / $138.66
| Professional | | $101.55 | $121.54 | $138.66 |