- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $315.43 / $315.43 / $315.43
| Facility | | $315.43 | $315.43 | $315.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.43 / $315.43 / $315.43
| Professional | | $315.43 | $315.43 | $315.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.50 / $22.50 / $22.50
| Professional | | $22.50 | $22.50 | $22.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $81.48 / $88.10 / $100.68
| Facility | | $81.48 | $88.10 | $100.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.48 / $2.48 / $3.10
| Professional | | $2.48 | $2.48 | $3.10 |