- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.52 / $154.52 / $397.33
| Facility | | $154.52 | $154.52 | $397.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.52 / $207.50 / $209.52
| Professional | | $154.52 | $207.50 | $209.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $332.27 / $444.79 / $496.67
| Professional | | $332.27 | $444.79 | $496.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.58 / $253.58 / $372.27
| Professional | | $253.58 | $253.58 | $372.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.44 / $172.18 / $397.33
| Facility | | $132.44 | $172.18 | $397.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.44 / $320.07 / $441.48
| Professional | | $132.44 | $320.07 | $441.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.71 / $282.55 / $378.50
| Professional | | $92.71 | $282.55 | $378.50 |