- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $271.67 / $271.67 / $271.67
| Facility | | $271.67 | $271.67 | $271.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.60 / $271.67 / $271.67
| Professional | | $128.60 | $271.67 | $271.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.20 / $224.20 / $224.20
| Professional | | $224.20 | $224.20 | $224.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $188.22 / $188.22 / $301.22
| Facility | | $188.22 | $188.22 | $301.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.40 / $188.22 / $263.76
| Professional | | $137.40 | $188.22 | $263.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.62 / $204.62 / $204.62
| Facility | | $204.62 | $204.62 | $204.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.18 / $148.94 / $226.37
| Professional | | $100.18 | $148.94 | $226.37 |