- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $365.77 / $365.77 / $365.77
| Facility | | $365.77 | $365.77 | $365.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.77 / $365.77 / $365.77
| Professional | | $185.77 | $365.77 | $365.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.86 / $323.86 / $323.86
| Professional | | $323.86 | $323.86 | $323.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $274.54 / $274.54 / $482.15
| Facility | | $274.54 | $274.54 | $482.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.41 / $200.41 / $559.13
| Professional | | $200.41 | $200.41 | $559.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.72 / $217.07 / $334.51
| Professional | | $144.72 | $217.07 | $334.51 |