- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $421.55 / $421.55 / $421.55
| Facility | | $421.55 | $421.55 | $421.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.10 / $421.55 / $421.55
| Professional | | $214.10 | $421.55 | $421.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.24 / $373.24 / $373.24
| Professional | | $373.24 | $373.24 | $373.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $344.22 / $344.22 / $532.11
| Facility | | $344.22 | $344.22 | $532.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.28 / $344.22 / $465.93
| Professional | | $251.28 | $344.22 | $465.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.79 / $250.18 / $385.52
| Professional | | $166.79 | $250.18 | $385.52 |