- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.75 / $143.75 / $143.75
| Facility | | $143.75 | $143.75 | $143.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.25 / $159.56 / $924.31
| Professional | | $86.25 | $159.56 | $924.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.10 / $154.47 / $179.70
| Professional | | $104.10 | $154.47 | $179.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.75 / $143.75 / $143.75
| Facility | | $143.75 | $143.75 | $143.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.88 / $174.64 / $295.76
| Professional | | $76.88 | $174.64 | $295.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.24 / $138.40 / $268.95
| Professional | | $52.24 | $138.40 | $268.95 |