- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $71.52 / $206.96 / $278.88
| Facility | | $71.52 | $206.96 | $278.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.52 / $71.52 / $71.52
| Professional | | $71.52 | $71.52 | $71.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.52 / $117.50 / $198.68
| Professional | | $71.52 | $117.50 | $198.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $67.47 / $67.47 / $71.52
| Facility | | $67.47 | $67.47 | $71.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.79 / $60.79 / $71.52
| Professional | | $60.79 | $60.79 | $71.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.08 / $71.52 / $115.92
| Professional | | $65.08 | $71.52 | $115.92 |