- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $575.44 / $575.44
| Facility | | $309.03 | $575.44 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $208.93 / $331.13
| Professional | | $169.82 | $208.93 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $288.40 / $457.09
| Professional | | $177.83 | $288.40 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.20 / $323.59 / $512.86
| Facility | | $112.20 | $323.59 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $295.12 / $691.83
| Professional | | $169.82 | $295.12 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $316.23 / $457.09
| Professional | | $194.98 | $316.23 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $263.03 / $575.44
| Professional | | $177.83 | $263.03 | $575.44 |