- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.83 / $257.83 / $257.83
| Facility | | $257.83 | $257.83 | $257.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.96 / $257.83 / $257.83
| Professional | | $130.96 | $257.83 | $257.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.29 / $170.29 / $305.07
| Facility | | $170.29 | $170.29 | $305.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.75 / $170.29 / $291.95
| Professional | | $144.75 | $170.29 | $291.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.64 / $153.02 / $210.66
| Professional | | $90.64 | $153.02 | $210.66 |