- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.63 / $229.63 / $229.63
| Facility | | $229.63 | $229.63 | $229.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.63 / $229.63 / $1,096.79
| Professional | | $229.63 | $229.63 | $1,096.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $227.25 / $251.07 / $748.04
| Facility | | $227.25 | $251.07 | $748.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.28 / $140.35 / $140.35
| Professional | | $112.28 | $140.35 | $140.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.63 / $229.63 / $751.81
| Facility | | $229.63 | $229.63 | $751.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.40 / $761.40 / $761.40
| Professional | | $761.40 | $761.40 | $761.40 |