- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $114.82 / $114.82
| Professional | | $56.23 | $114.82 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.13 / $158.49 / $213.80
| Facility | | $89.13 | $158.49 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.62 / $1.62 / $1.62
| Professional | | $1.62 | $1.62 | $1.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Facility | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $72.44 / $79.43
| Professional | | $72.44 | $72.44 | $79.43 |