- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $46.97 / $120.85 / $528.87
| Facility | | $46.97 | $120.85 | $528.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.62 / $87.35 / $120.85
| Professional | | $46.62 | $87.35 | $120.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.76 / $209.04 / $209.04
| Professional | | $49.76 | $209.04 | $209.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.12 / $87.12 / $87.12
| Professional | | $87.12 | $87.12 | $87.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $87.35 / $87.35 / $122.29
| Facility | | $87.35 | $87.35 | $122.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |