- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $219.81 / $325.94 / $403.72
| Facility | | $219.81 | $325.94 | $403.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.00 / $219.81 / $244.00
| Professional | | $180.00 | $219.81 | $244.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.36 / $154.36 / $154.36
| Facility | | $154.36 | $154.36 | $154.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $241.37 / $241.37 / $241.37
| Facility | | $241.37 | $241.37 | $241.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.37 / $241.37 / $241.37
| Professional | | $241.37 | $241.37 | $241.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.00 / $136.26 / $151.41
| Professional | | $20.00 | $136.26 | $151.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.51 / $239.43 / $258.61
| Professional | | $215.51 | $239.43 | $258.61 |