- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.70 / $134.87 / $134.87
| Professional | | $100.70 | $134.87 | $134.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.76 / $160.76 / $160.76
| Professional | | $160.76 | $160.76 | $160.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.68 / $130.68 / $171.51
| Facility | | $130.68 | $130.68 | $171.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.08 / $130.68 / $171.51
| Professional | | $111.08 | $130.68 | $171.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.68 / $130.68 / $171.51
| Facility | | $130.68 | $130.68 | $171.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.68 / $130.68 / $171.51
| Professional | | $130.68 | $130.68 | $171.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.59 / $143.74 / $185.92
| Professional | | $65.59 | $143.74 | $185.92 |