- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.95 / $171.07 / $783.34
| Facility | | $104.95 | $171.07 | $783.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.73 / $104.73 / $126.99
| Professional | | $104.73 | $104.73 | $126.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.68 / $118.68 / $118.68
| Professional | | $118.68 | $118.68 | $118.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.73 / $104.73 / $104.73
| Facility | | $104.73 | $104.73 | $104.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.73 / $104.73 / $104.73
| Professional | | $104.73 | $104.73 | $104.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.68 / $502.50 / $523.65
| Facility | | $133.68 | $502.50 | $523.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.73 / $104.73 / $105.92
| Professional | | $104.73 | $104.73 | $105.92 |