- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.49 / $158.49 / $158.49
| Facility | | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $158.49 / $158.49
| Professional | | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.12 / $25.12 / $25.12
| Professional | | $25.12 | $25.12 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $169.82 / $346.74
| Professional | | $120.23 | $169.82 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |