- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $233.36 / $233.36 / $233.36
| Facility | | $233.36 | $233.36 | $233.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.41 / $182.08 / $233.36
| Professional | | $150.41 | $182.08 | $233.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.38 / $216.38 / $216.38
| Professional | | $216.38 | $216.38 | $216.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $233.36 / $318.20 / $469.67
| Facility | | $233.36 | $318.20 | $469.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.57 / $254.57 / $285.12
| Professional | | $254.57 | $254.57 | $285.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.57 / $254.57 / $285.12
| Professional | | $254.57 | $254.57 | $285.12 |