- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.82 / $108.27 / $367.57
| Professional | | $58.82 | $108.27 | $367.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.45 / $70.45 / $128.82
| Professional | | $70.45 | $70.45 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.45 / $70.45 / $70.45
| Facility | | $70.45 | $70.45 | $70.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.44 / $111.15 / $193.22
| Professional | | $60.44 | $111.15 | $193.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.13 / $70.45 / $170.03
| Facility | | $35.13 | $70.45 | $170.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.50 / $99.74 / $177.37
| Professional | | $60.50 | $99.74 | $177.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.45 / $118.21 / $196.03
| Professional | | $102.45 | $118.21 | $196.03 |