- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $301.35 / $301.35 / $640.37
| Facility | | $301.35 | $301.35 | $640.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.35 / $301.35 / $301.35
| Professional | | $301.35 | $301.35 | $301.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.54 / $120.54 / $195.87
| Professional | | $120.54 | $120.54 | $195.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.35 / $361.05 / $534.87
| Professional | | $301.35 | $361.05 | $534.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $301.35 / $301.35 / $488.19
| Facility | | $301.35 | $301.35 | $488.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.35 / $301.35 / $301.35
| Professional | | $301.35 | $301.35 | $301.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.69 / $180.81 / $527.36
| Professional | | $153.69 | $180.81 | $527.36 |