- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.37 / $168.37 / $194.27
| Professional | | $168.37 | $168.37 | $194.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $279.12 / $279.12 / $279.12
| Professional | | $279.12 | $279.12 | $279.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.78 / $190.78 / $253.59
| Facility | | $190.78 | $190.78 | $253.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.27 / $190.78 / $203.38
| Professional | | $139.27 | $190.78 | $203.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.78 / $190.78 / $253.59
| Facility | | $190.78 | $190.78 | $253.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.27 / $190.78 / $203.38
| Professional | | $139.27 | $190.78 | $203.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.75 / $259.29 / $286.87
| Professional | | $114.75 | $259.29 | $286.87 |