- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.45 / $124.93 / $196.68
| Professional | | $112.45 | $124.93 | $196.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.36 / $50.36 / $127.31
| Facility | | $50.36 | $50.36 | $127.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.09 / $145.71 / $242.85
| Facility | | $106.09 | $145.71 | $242.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.45 / $112.45 / $112.45
| Professional | | $112.45 | $112.45 | $112.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.09 / $145.71 / $242.85
| Facility | | $106.09 | $145.71 | $242.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.45 / $112.45 / $112.45
| Professional | | $112.45 | $112.45 | $112.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.83 / $112.45 / $367.84
| Professional | | $106.83 | $112.45 | $367.84 |