- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.56 / $172.56 / $443.74
| Facility | | $172.56 | $172.56 | $443.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.56 / $231.73 / $231.73
| Professional | | $172.56 | $231.73 | $231.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.07 / $496.74 / $554.66
| Professional | | $371.07 | $496.74 | $554.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.32 / $283.32 / $415.92
| Professional | | $283.32 | $283.32 | $415.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $41.65 / $177.49 / $443.74
| Facility | | $41.65 | $177.49 | $443.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.74 / $295.82 / $493.04
| Professional | | $126.74 | $295.82 | $493.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.54 / $258.85 / $473.56
| Professional | | $103.54 | $258.85 | $473.56 |