- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $222.66 / $222.66 / $222.66
| Facility | | $222.66 | $222.66 | $222.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.77 / $222.66 / $393.92
| Professional | | $195.77 | $222.66 | $393.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.00 / $319.98 / $476.86
| Professional | | $260.00 | $319.98 | $476.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.37 / $218.27 / $240.99
| Facility | | $200.37 | $218.27 | $240.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.34 / $218.27 / $270.52
| Professional | | $159.34 | $218.27 | $270.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $183.12 / $305.56 / $554.72
| Facility | | $183.12 | $305.56 | $554.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.00 / $253.00 / $272.00
| Professional | | $253.00 | $253.00 | $272.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.99 / $303.99 / $303.99
| Professional | | $303.99 | $303.99 | $303.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.27 / $200.22 / $253.61
| Professional | | $140.27 | $200.22 | $253.61 |