- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.96 / $115.67 / $133.46
| Professional | | $63.96 | $115.67 | $133.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.77 / $191.77 / $191.77
| Professional | | $191.77 | $191.77 | $191.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.33 / $138.33 / $203.46
| Facility | | $138.33 | $138.33 | $203.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.98 / $100.98 / $120.11
| Professional | | $100.98 | $100.98 | $120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.33 / $138.33 / $203.46
| Facility | | $138.33 | $138.33 | $203.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.98 / $100.98 / $120.11
| Professional | | $100.98 | $100.98 | $120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.99 / $140.41 / $274.02
| Professional | | $81.99 | $140.41 | $274.02 |