- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.82 / $346.82 / $346.82
| Facility | | $346.82 | $346.82 | $346.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.15 / $346.82 / $346.82
| Professional | | $176.15 | $346.82 | $346.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.08 / $307.08 / $307.08
| Professional | | $307.08 | $307.08 | $307.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.78 / $239.78 / $370.68
| Facility | | $239.78 | $239.78 | $370.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.04 / $239.78 / $324.57
| Professional | | $175.04 | $239.78 | $324.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $247.02 / $247.02 / $247.02
| Facility | | $247.02 | $247.02 | $247.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.28 / $205.83 / $284.95
| Professional | | $123.28 | $205.83 | $284.95 |