- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.75 / $375.75 / $375.75
| Facility | | $375.75 | $375.75 | $375.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.84 / $375.75 / $375.75
| Professional | | $190.84 | $375.75 | $375.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.33 / $302.33 / $302.33
| Professional | | $302.33 | $302.33 | $302.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $286.80 / $286.80 / $444.59
| Facility | | $286.80 | $286.80 | $444.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.36 / $209.36 / $515.25
| Professional | | $209.36 | $209.36 | $515.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.09 / $223.01 / $319.35
| Professional | | $132.09 | $223.01 | $319.35 |