- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.65 / $182.65 / $182.65
| Facility | | $182.65 | $182.65 | $182.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.50 / $182.65 / $217.79
| Professional | | $144.50 | $182.65 | $217.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.08 / $311.67 / $366.67
| Professional | | $269.08 | $311.67 | $366.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.75 / $176.50 / $221.93
| Professional | | $174.75 | $176.50 | $221.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.82 / $182.65 / $228.47
| Facility | | $150.82 | $182.65 | $228.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.67 / $338.26 / $1,105.55
| Professional | | $187.67 | $338.26 | $1,105.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.67 / $332.18 / $454.80
| Professional | | $187.67 | $332.18 | $454.80 |