- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.70 / $275.70 / $275.70
| Facility | | $275.70 | $275.70 | $275.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.83 / $275.70 / $275.70
| Professional | | $264.83 | $275.70 | $275.70 |
- 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
- $303.83 / $357.47 / $357.47
| Professional | | $303.83 | $357.47 | $357.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $226.63 / $226.63 / $226.63
| Facility | | $226.63 | $226.63 | $226.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.64 / $192.64 / $226.63
| Professional | | $192.64 | $192.64 | $226.63 |