- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $319.36 / $319.36 / $319.36
| Facility | | $319.36 | $319.36 | $319.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $319.36 / $319.36
| Professional | | $151.16 | $319.36 | $319.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.50 / $239.50 / $239.50
| Professional | | $239.50 | $239.50 | $239.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.98 / $212.98 / $352.24
| Facility | | $212.98 | $212.98 | $352.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.47 / $212.98 / $337.04
| Professional | | $155.47 | $212.98 | $337.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.64 / $156.97 / $243.19
| Professional | | $104.64 | $156.97 | $243.19 |