- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.56 / $165.56 / $165.56
| Facility | | $165.56 | $165.56 | $165.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.75 / $43.30 / $43.30
| Professional | | $40.75 | $43.30 | $43.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.73 / $330.73 / $367.48
| Facility | | $330.73 | $330.73 | $367.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.87 / $28.87 / $28.87
| Facility | | $28.87 | $28.87 | $28.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.87 / $28.87 / $28.87
| Professional | | $28.87 | $28.87 | $28.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.53 / $40.53 / $43.57
| Professional | | $40.53 | $40.53 | $43.57 |