- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $285.55 / $285.55 / $285.55
| Facility | | $285.55 | $285.55 | $285.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.32 / $285.55 / $285.55
| Professional | | $135.32 | $285.55 | $285.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.64 / $295.67 / $397.78
| Facility | | $243.64 | $295.67 | $397.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.96 / $182.80 / $215.70
| Professional | | $127.96 | $182.80 | $215.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.69 / $149.69 / $149.69
| Professional | | $149.69 | $149.69 | $149.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.96 / $183.53 / $217.61
| Professional | | $112.96 | $183.53 | $217.61 |