- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $258.81 / $258.81 / $258.81
| Facility | | $258.81 | $258.81 | $258.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.44 / $258.81 / $258.81
| Professional | | $131.44 | $258.81 | $258.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.15 / $229.15 / $229.15
| Professional | | $229.15 | $229.15 | $229.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $265.56 / $265.56 / $410.50
| Facility | | $265.56 | $265.56 | $410.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.86 / $265.56 / $359.45
| Professional | | $193.86 | $265.56 | $359.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.40 / $153.60 / $236.69
| Professional | | $102.40 | $153.60 | $236.69 |