- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.45 / $104.36 / $440.41
| Professional | | $72.45 | $104.36 | $440.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.14 / $125.14 / $125.14
| Facility | | $125.14 | $125.14 | $125.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.95 / $125.14 / $187.53
| Professional | | $80.95 | $125.14 | $187.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.02 / $137.44 / $185.32
| Facility | | $89.02 | $137.44 | $185.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.47 / $157.78 / $237.54
| Professional | | $100.47 | $157.78 | $237.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.25 / $166.46 / $183.68
| Professional | | $140.25 | $166.46 | $183.68 |