- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.86 / $217.86 / $267.75
| Facility | | $217.86 | $217.86 | $267.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.86 / $239.81 / $267.75
| Professional | | $217.86 | $239.81 | $267.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.93 / $194.93 / $304.77
| Professional | | $194.93 | $194.93 | $304.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.36 / $191.36 / $191.36
| Professional | | $191.36 | $191.36 | $191.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.81 / $460.10 / $1,267.32
| Facility | | $239.81 | $460.10 | $1,267.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.68 / $260.75 / $501.68
| Professional | | $204.68 | $260.75 | $501.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.93 / $277.44 / $510.56
| Professional | | $207.93 | $277.44 | $510.56 |