- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.71 / $57.40 / $182.86
| Facility | | $54.71 | $57.40 | $182.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.86 / $182.86 / $182.86
| Professional | | $182.86 | $182.86 | $182.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.74 / $227.29 / $227.29
| Professional | | $172.74 | $227.29 | $227.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.25 / $179.84 / $179.84
| Professional | | $5.25 | $179.84 | $179.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.86 / $182.86 / $237.72
| Facility | | $182.86 | $182.86 | $237.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.00 / $100.00 / $100.00
| Facility | | $90.00 | $100.00 | $100.00 |