- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $81.28 / $239.88
| Professional | | $57.54 | $81.28 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.09 / $309.03 / $363.08
| Facility | | $229.09 | $309.03 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $102.33 / $165.96
| Professional | | $75.86 | $102.33 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.13 / $89.13 / $102.33
| Facility | | $89.13 | $89.13 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $75.86 / $102.33
| Professional | | $75.86 | $75.86 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $81.28 / $177.83
| Facility | | $64.57 | $81.28 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $83.18 / $128.82
| Professional | | $66.07 | $83.18 | $128.82 |