- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.35 / $275.35 / $585.12
| Facility | | $275.35 | $275.35 | $585.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.44 / $245.44 / $245.44
| Professional | | $245.44 | $245.44 | $245.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.14 / $110.14 / $178.97
| Professional | | $110.14 | $110.14 | $178.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.35 / $275.35 / $278.10
| Professional | | $275.35 | $275.35 | $278.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.35 / $275.35 / $446.07
| Facility | | $275.35 | $275.35 | $446.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.44 / $245.44 / $275.35
| Professional | | $245.44 | $245.44 | $275.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.43 / $165.21 / $481.86
| Professional | | $140.43 | $165.21 | $481.86 |