- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.79 / $71.68 / $110.40
| Professional | | $39.79 | $71.68 | $110.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.52 / $112.52 / $133.75
| Facility | | $112.52 | $112.52 | $133.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.14 / $101.27 / $112.52
| Professional | | $73.14 | $101.27 | $112.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61.60 / $74.98 / $112.52
| Facility | | $61.60 | $74.98 | $112.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.51 / $101.27 / $149.44
| Professional | | $91.51 | $101.27 | $149.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.13 / $117.15 / $133.31
| Professional | | $91.13 | $117.15 | $133.31 |