- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $271.63 / $271.63 / $271.63
| Facility | | $271.63 | $271.63 | $271.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.58 / $271.63 / $271.63
| Professional | | $128.58 | $271.63 | $271.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.16 / $224.16 / $224.16
| Professional | | $224.16 | $224.16 | $224.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $188.19 / $188.19 / $301.17
| Facility | | $188.19 | $188.19 | $301.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.38 / $188.19 / $263.72
| Professional | | $137.38 | $188.19 | $263.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.17 / $150.25 / $226.33
| Professional | | $100.17 | $150.25 | $226.33 |