- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.46 / $217.46 / $217.46
| Facility | | $217.46 | $217.46 | $217.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.51 / $217.46 / $217.46
| Professional | | $94.51 | $217.46 | $217.46 |
- 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 / $471.78 / $615.53
| Facility | | $44.21 | $471.78 | $615.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $94.52 / $217.46 / $253.93
| Facility | | $94.52 | $217.46 | $253.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |