- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.46 / $169.46 / $169.46
| Facility | | $169.46 | $169.46 | $169.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $159.38 / $169.46
| Professional | | $123.03 | $159.38 | $169.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.04 / $301.04 / $319.85
| Professional | | $301.04 | $301.04 | $319.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $482.61 / $482.61 / $482.61
| Facility | | $482.61 | $482.61 | $482.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.22 / $410.22 / $482.61
| Professional | | $410.22 | $410.22 | $482.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.52 / $167.02 / $376.21
| Professional | | $103.52 | $167.02 | $376.21 |