- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $341.46 / $341.46 / $341.46
| Facility | | $341.46 | $341.46 | $341.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.63 / $341.46 / $341.46
| Professional | | $161.63 | $341.46 | $341.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.85 / $250.85 / $250.85
| Professional | | $250.85 | $250.85 | $250.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $236.57 / $236.57 / $378.59
| Facility | | $236.57 | $236.57 | $378.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.70 / $236.57 / $331.51
| Professional | | $172.70 | $236.57 | $331.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.92 / $188.88 / $284.52
| Professional | | $125.92 | $188.88 | $284.52 |