- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $198.33 / $427.49 / $881.32
| Facility | | $198.33 | $427.49 | $881.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.45 / $182.45 / $182.45
| Professional | | $182.45 | $182.45 | $182.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.45 / $294.92 / $498.68
| Professional | | $182.45 | $294.92 | $498.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.12 / $172.12 / $182.45
| Facility | | $172.12 | $172.12 | $182.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.08 / $155.08 / $182.45
| Professional | | $155.08 | $155.08 | $182.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.03 / $182.45 / $295.70
| Professional | | $166.03 | $182.45 | $295.70 |