- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $262.72 / $262.72 / $558.28
| Facility | | $262.72 | $262.72 | $558.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.80 / $212.80 / $212.80
| Professional | | $212.80 | $212.80 | $212.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.63 / $205.82 / $205.82
| Professional | | $157.63 | $205.82 | $205.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.72 / $262.72 / $265.35
| Professional | | $262.72 | $262.72 | $265.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $262.72 / $262.72 / $425.61
| Facility | | $262.72 | $262.72 | $425.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.80 / $212.80 / $262.72
| Professional | | $212.80 | $212.80 | $262.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.99 / $157.63 / $394.08
| Professional | | $133.99 | $157.63 | $394.08 |