- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $119.63 / $119.63 / $119.63
| Facility | | $119.63 | $119.63 | $119.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.47 / $85.69 / $119.63
| Professional | | $81.47 | $85.69 | $119.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.74 / $181.77 / $186.30
| Professional | | $153.74 | $181.77 | $186.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.88 / $144.30 / $181.45
| Professional | | $142.88 | $144.30 | $181.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.23 / $119.63 / $647.48
| Facility | | $57.23 | $119.63 | $647.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.27 / $68.31 / $131.02
| Professional | | $51.27 | $68.31 | $131.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.02 / $68.31 / $131.02
| Professional | | $41.02 | $68.31 | $131.02 |