- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $320.63 / $320.63 / $320.63
| Facility | | $320.63 | $320.63 | $320.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.85 / $320.63 / $320.63
| Professional | | $162.85 | $320.63 | $320.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.07 / $324.22 / $381.43
| Professional | | $286.07 | $324.22 | $381.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.37 / $245.37 / $245.37
| Professional | | $245.37 | $245.37 | $245.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $248.05 / $248.05 / $381.43
| Facility | | $248.05 | $248.05 | $381.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.08 / $248.05 / $333.99
| Professional | | $181.08 | $248.05 | $333.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.86 / $190.30 / $303.85
| Professional | | $126.86 | $190.30 | $303.85 |