- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.50 / $294.44 / $294.44
| Facility | | $134.50 | $294.44 | $294.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.50 / $294.44 / $326.83
| Professional | | $202.50 | $294.44 | $326.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $210.33 / $210.33 / $210.33
| Facility | | $210.33 | $210.33 | $210.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $207.56 / $323.87 / $323.87
| Facility | | $207.56 | $323.87 | $323.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.87 / $323.87 / $323.87
| Professional | | $323.87 | $323.87 | $323.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $17.00 / $20.00
| Professional | | $17.00 | $17.00 | $20.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.17 / $326.76 / $346.40
| Professional | | $289.17 | $326.76 | $346.40 |