- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.98 / $194.98 / $194.98
| Facility | | $194.98 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $131.83 / $204.17
| Professional | | $114.82 | $131.83 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $186.21 / $186.21
| Professional | | $169.82 | $186.21 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $109.65
| Professional | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $44.67 / $44.67
| Professional | | $44.67 | $44.67 | $44.67 |