- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.45 / $208.45 / $212.78
| Facility | | $208.45 | $208.45 | $212.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.94 / $212.78 / $316.66
| Professional | | $156.94 | $212.78 | $316.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $391.17 / $479.61 / $525.38
| Professional | | $391.17 | $479.61 | $525.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.98 / $436.28 / $656.08
| Professional | | $235.98 | $436.28 | $656.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.45 / $294.02 / $411.55
| Facility | | $208.45 | $294.02 | $411.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.44 / $424.44 / $1,299.72
| Professional | | $233.44 | $424.44 | $1,299.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.44 / $390.34 / $501.49
| Professional | | $233.44 | $390.34 | $501.49 |