- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.75 / $52.79 / $109.65
| Facility | | $45.75 | $52.79 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.75 / $45.75 / $59.97
| Professional | | $45.75 | $45.75 | $59.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.57 / $504.43 / $504.43
| Professional | | $162.57 | $504.43 | $504.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.08 / $139.08 / $139.08
| Facility | | $139.08 | $139.08 | $139.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.53 / $101.53 / $225.75
| Professional | | $101.53 | $101.53 | $225.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.00 / $200.00 / $493.00
| Professional | | $200.00 | $200.00 | $493.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.95 / $73.40 / $136.72
| Professional | | $45.95 | $73.40 | $136.72 |