- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.96 / $129.96 / $129.96
| Facility | | $129.96 | $129.96 | $129.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.96 / $145.37 / $165.40
| Professional | | $129.96 | $145.37 | $165.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.38 / $216.38 / $216.38
| Professional | | $216.38 | $216.38 | $216.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.96 / $165.40 / $468.65
| Facility | | $129.96 | $165.40 | $468.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.57 / $254.57 / $1,351.44
| Professional | | $254.57 | $254.57 | $1,351.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.57 / $254.57 / $280.70
| Professional | | $254.57 | $254.57 | $280.70 |