- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.88 / $132.88 / $132.88
| Facility | | $132.88 | $132.88 | $132.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.88 / $132.88 / $132.88
| Professional | | $132.88 | $132.88 | $132.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.41 / $191.97 / $323.92
| Facility | | $108.41 | $191.97 | $323.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.21 / $149.68 / $235.24
| Facility | | $44.21 | $149.68 | $235.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.88 / $164.77 / $278.10
| Facility | | $132.88 | $164.77 | $278.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |