- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.69 / $119.69 / $261.98
| Facility | | $79.69 | $119.69 | $261.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.69 / $79.69 / $79.69
| Professional | | $79.69 | $79.69 | $79.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.62 / $71.72 / $87.45
| Professional | | $59.62 | $71.72 | $87.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.50 / $79.50 / $79.50
| Facility | | $79.50 | $79.50 | $79.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.50 / $79.50 / $79.50
| Professional | | $79.50 | $79.50 | $79.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.69 / $79.69 / $79.69
| Professional | | $79.69 | $79.69 | $79.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.62 / $90.69 / $100.67
| Professional | | $81.62 | $90.69 | $100.67 |