- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.97 / $111.97 / $287.91
| Facility | | $111.97 | $111.97 | $287.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.97 / $111.97 / $111.97
| Professional | | $111.97 | $111.97 | $111.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.91 / $322.30 / $361.69
| Professional | | $265.91 | $322.30 | $361.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.79 / $185.62 / $233.41
| Professional | | $183.79 | $185.62 | $233.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.97 / $190.35 / $759.76
| Facility | | $111.97 | $190.35 | $759.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.18 / $159.94 / $271.92
| Professional | | $67.18 | $159.94 | $271.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.18 / $163.15 / $223.93
| Professional | | $67.18 | $163.15 | $223.93 |