- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.18 / $104.90 / $148.59
| Professional | | $79.18 | $104.90 | $148.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.45 / $106.45 / $106.45
| Professional | | $106.45 | $106.45 | $106.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.67 / $164.67 / $164.67
| Professional | | $164.67 | $164.67 | $164.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.12 / $129.12 / $131.69
| Facility | | $129.12 | $129.12 | $131.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.75 / $129.12 / $202.50
| Professional | | $109.75 | $129.12 | $202.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.56 / $81.20 / $171.85
| Professional | | $53.56 | $81.20 | $171.85 |