- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $189.26 / $189.26 / $227.99
| Facility | | $189.26 | $189.26 | $227.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.72 / $152.38 / $189.26
| Professional | | $151.72 | $152.38 | $189.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.49 / $304.77 / $335.27
| Professional | | $253.49 | $304.77 | $335.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.62 / $252.48 / $371.76
| Professional | | $155.62 | $252.48 | $371.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.88 / $189.99 / $383.93
| Facility | | $156.88 | $189.99 | $383.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.19 / $351.97 / $1,140.68
| Professional | | $190.19 | $351.97 | $1,140.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.97 / $351.97 / $476.89
| Professional | | $158.97 | $351.97 | $476.89 |