- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $247.40 / $247.40 / $247.40
| Facility | | $247.40 | $247.40 | $247.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.40 / $247.40 / $256.27
| Professional | | $247.40 | $247.40 | $256.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.26 / $35.75 / $35.75
| Facility | | $32.26 | $35.75 | $35.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.93 / $357.47 / $386.07
| Professional | | $354.93 | $357.47 | $386.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.83 / $170.83 / $170.83
| Facility | | $170.83 | $170.83 | $170.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.21 / $170.83 / $170.83
| Professional | | $145.21 | $170.83 | $170.83 |