- 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
- $260.31 / $275.70 / $275.70
| Professional | | $260.31 | $275.70 | $275.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.34 / $145.34 / $145.34
| Professional | | $145.34 | $145.34 | $145.34 |
- 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 / $226.63 / $226.63
| Professional | | $192.64 | $226.63 | $226.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.00 / $275.70 / $275.70
| Facility | | $90.00 | $275.70 | $275.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.31 / $260.31 / $260.31
| Professional | | $260.31 | $260.31 | $260.31 |