- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $320.10 / $320.10 / $320.10
| Facility | | $320.10 | $320.10 | $320.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.42 / $246.23 / $246.23
| Professional | | $123.42 | $246.23 | $246.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.47 / $246.23 / $246.23
| Facility | | $122.47 | $246.23 | $246.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.47 / $246.23 / $246.23
| Facility | | $122.47 | $246.23 | $246.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.12 / $20.12 / $20.12
| Professional | | $20.12 | $20.12 | $20.12 |