- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.47 / $389.47 / $389.47
| Facility | | $389.47 | $389.47 | $389.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.37 / $389.47 / $389.47
| Professional | | $184.37 | $389.47 | $389.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.07 / $292.07 / $292.07
| Professional | | $292.07 | $292.07 | $292.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.01 / $252.01 / $429.50
| Facility | | $252.01 | $252.01 | $429.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.97 / $252.01 / $376.08
| Professional | | $183.97 | $252.01 | $376.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.61 / $191.41 / $296.58
| Professional | | $127.61 | $191.41 | $296.58 |