- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $388.57 / $388.57 / $388.57
| Facility | | $388.57 | $388.57 | $388.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.93 / $388.57 / $388.57
| Professional | | $183.93 | $388.57 | $388.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.66 / $320.66 / $320.66
| Professional | | $320.66 | $320.66 | $320.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.20 / $253.20 / $449.64
| Facility | | $253.20 | $253.20 | $449.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.84 / $253.20 / $393.72
| Professional | | $184.84 | $253.20 | $393.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.77 / $202.16 / $304.52
| Professional | | $134.77 | $202.16 | $304.52 |