- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.65 / $168.96 / $237.95
| Professional | | $64.65 | $168.96 | $237.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.02 / $98.85 / $245.55
| Professional | | $84.02 | $98.85 | $245.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.85 / $98.85 / $291.88
| Facility | | $98.85 | $98.85 | $291.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.02 / $143.94 / $273.76
| Professional | | $84.02 | $143.94 | $273.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.05 / $144.59 / $290.55
| Facility | | $54.05 | $144.59 | $290.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.02 / $150.60 / $298.88
| Professional | | $84.02 | $150.60 | $298.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.72 / $271.99 / $292.18
| Professional | | $239.72 | $271.99 | $292.18 |