- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $214.62 / $392.75 / $435.68
| Facility | | $214.62 | $392.75 | $435.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.55 / $392.75 / $435.68
| Professional | | $169.55 | $392.75 | $435.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $214.62 / $214.62 / $214.62
| Facility | | $214.62 | $214.62 | $214.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.62 / $214.62 / $214.62
| Professional | | $214.62 | $214.62 | $214.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.50 / $162.80 / $327.33
| Facility | | $139.50 | $162.80 | $327.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.91 / $170.95 / $367.62
| Professional | | $91.91 | $170.95 | $367.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.14 / $128.77 / $366.35
| Professional | | $90.14 | $128.77 | $366.35 |