- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $283.56 / $283.56 / $283.56
| Facility | | $283.56 | $283.56 | $283.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.02 / $283.56 / $283.56
| Professional | | $144.02 | $283.56 | $283.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.49 / $223.49 / $223.49
| Professional | | $223.49 | $223.49 | $223.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $221.07 / $221.07 / $341.73
| Facility | | $221.07 | $221.07 | $341.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.38 / $221.07 / $299.23
| Professional | | $161.38 | $221.07 | $299.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.88 / $168.29 / $244.74
| Professional | | $105.88 | $168.29 | $244.74 |