- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.42 / $127.56 / $127.56
| Facility | | $93.42 | $127.56 | $127.56 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $70.06 / $70.06 / $95.67
| Facility | 54 | $70.06 | $70.06 | $95.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.41 / $180.48 / $297.92
| Facility | | $131.41 | $180.48 | $297.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.44 / $234.03 / $313.27
| Facility | | $159.44 | $234.03 | $313.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.39 / $186.95 / $251.64
| Professional | | $126.39 | $186.95 | $251.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $821.00 / $821.00 / $821.00
| Facility | | $821.00 | $821.00 | $821.00 |