- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.59 / $268.61 / $439.07
| Facility | | $206.59 | $268.61 | $439.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.59 / $206.59 / $250.01
| Professional | | $206.59 | $206.59 | $250.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.46 / $231.46 / $231.46
| Professional | | $231.46 | $231.46 | $231.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.59 / $206.59 / $206.59
| Facility | | $206.59 | $206.59 | $206.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.59 / $206.59 / $206.59
| Professional | | $206.59 | $206.59 | $206.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $268.13 / $1,007.85 / $1,032.95
| Facility | | $268.13 | $1,007.85 | $1,032.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.59 / $206.59 / $206.59
| Professional | | $206.59 | $206.59 | $206.59 |