- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.60 / $238.60 / $238.60
| Facility | | $238.60 | $238.60 | $238.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.18 / $238.60 / $238.60
| Professional | | $121.18 | $238.60 | $238.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.26 / $211.26 / $211.26
| Professional | | $211.26 | $211.26 | $211.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.96 / $169.96 / $246.18
| Facility | | $169.96 | $169.96 | $246.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.07 / $124.07 / $285.38
| Professional | | $124.07 | $124.07 | $285.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.43 / $141.61 / $177.01
| Professional | | $74.43 | $141.61 | $177.01 |