- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $183.35 / $183.35 / $407.28
| Facility | | $183.35 | $183.35 | $407.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.35 / $183.35 / $183.35
| Professional | | $183.35 | $183.35 | $183.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.63 / $151.84 / $475.91
| Facility | | $147.63 | $151.84 | $475.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.98 / $185.62 / $316.32
| Professional | | $163.98 | $185.62 | $316.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.73 / $198.64 / $699.56
| Facility | | $172.73 | $198.64 | $699.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.37 / $211.80 / $266.58
| Professional | | $186.37 | $211.80 | $266.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.55 / $85.56 / $103.64
| Professional | | $72.55 | $85.56 | $103.64 |