- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.63 / $261.01 / $289.54
| Facility | | $142.63 | $261.01 | $289.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.68 / $261.01 / $289.54
| Professional | | $112.68 | $261.01 | $289.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.25 / $26.25 / $26.25
| Facility | | $26.25 | $26.25 | $26.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.25 / $26.25 / $26.25
| Professional | | $26.25 | $26.25 | $26.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $92.71 / $97.35 / $108.19
| Facility | | $92.71 | $97.35 | $108.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.90 / $85.58 / $213.95
| Professional | | $59.90 | $85.58 | $213.95 |