- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $320.55 / $320.55 / $320.55
| Facility | | $320.55 | $320.55 | $320.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.74 / $320.55 / $320.55
| Professional | | $151.74 | $320.55 | $320.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.52 / $264.52 / $264.52
| Professional | | $264.52 | $264.52 | $264.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.89 / $243.89 / $377.04
| Facility | | $243.89 | $243.89 | $377.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.04 / $178.04 / $437.25
| Professional | | $178.04 | $178.04 | $437.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.21 / $177.31 / $267.08
| Professional | | $118.21 | $177.31 | $267.08 |