- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $88.80 / $182.44 / $595.74
| Facility | | $88.80 | $182.44 | $595.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.45 / $182.45 / $202.69
| Professional | | $182.45 | $182.45 | $202.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.41 / $257.77 / $346.78
| Facility | | $212.41 | $257.77 | $346.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.45 / $182.45 / $282.24
| Professional | | $182.45 | $182.45 | $282.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.45 / $182.45 / $182.45
| Facility | | $182.45 | $182.45 | $182.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.45 / $182.45 / $362.47
| Professional | | $182.45 | $182.45 | $362.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.45 / $182.45 / $182.45
| Professional | | $182.45 | $182.45 | $182.45 |