- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $420.44 / $420.44 / $420.44
| Facility | | $420.44 | $420.44 | $420.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.54 / $420.44 / $420.44
| Professional | | $213.54 | $420.44 | $420.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $372.27 / $372.27 / $372.27
| Professional | | $372.27 | $372.27 | $372.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $280.67 / $280.67 / $476.75
| Facility | | $280.67 | $280.67 | $476.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.89 / $280.67 / $417.46
| Professional | | $204.89 | $280.67 | $417.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.12 / $249.53 / $320.58
| Professional | | $135.12 | $249.53 | $320.58 |