- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $340.37 / $340.37 / $340.37
| Facility | | $340.37 | $340.37 | $340.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.73 / $104.73 / $108.92
| Professional | | $104.73 | $104.73 | $108.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.95 / $104.95 / $110.89
| Facility | | $104.95 | $104.95 | $110.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.73 / $104.73 / $104.73
| Professional | | $104.73 | $104.73 | $104.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.80 / $104.73 / $104.73
| Facility | | $98.80 | $104.73 | $104.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.73 / $104.73 / $104.73
| Professional | | $104.73 | $104.73 | $104.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.73 / $104.73 / $104.73
| Professional | | $104.73 | $104.73 | $104.73 |