- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $183.90 / $183.90 / $472.90
| Facility | | $183.90 | $183.90 | $472.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.90 / $246.96 / $246.96
| Professional | | $183.90 | $246.96 | $246.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.46 / $529.38 / $591.12
| Professional | | $395.46 | $529.38 | $591.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.89 / $301.89 / $443.21
| Professional | | $301.89 | $301.89 | $443.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.63 / $199.67 / $472.90
| Facility | | $157.63 | $199.67 | $472.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.99 / $315.26 / $525.44
| Professional | | $133.99 | $315.26 | $525.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.34 / $267.97 / $446.62
| Professional | | $110.34 | $267.97 | $446.62 |