- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.36 / $309.36 / $309.36
| Facility | | $309.36 | $309.36 | $309.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.12 / $309.36 / $309.36
| Professional | | $157.12 | $309.36 | $309.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.91 / $273.91 / $273.91
| Professional | | $273.91 | $273.91 | $273.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $292.48 / $292.48 / $452.13
| Facility | | $292.48 | $292.48 | $452.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.51 / $292.48 / $395.90
| Professional | | $213.51 | $292.48 | $395.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.04 / $183.60 / $279.77
| Professional | | $121.04 | $183.60 | $279.77 |