- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $322.91 / $322.91 / $322.91
| Facility | | $322.91 | $322.91 | $322.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.86 / $322.91 / $322.91
| Professional | | $152.86 | $322.91 | $322.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.48 / $266.48 / $266.48
| Professional | | $266.48 | $266.48 | $266.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $227.07 / $227.07 / $391.49
| Facility | | $227.07 | $227.07 | $391.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.76 / $227.07 / $342.80
| Professional | | $165.76 | $227.07 | $342.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.08 / $177.02 / $269.06
| Professional | | $119.08 | $177.02 | $269.06 |