- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $199.53 / $199.53
| Facility | | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $213.80 / $323.59
| Professional | | $199.53 | $213.80 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.42 / $407.38 / $512.86
| Facility | | $234.42 | $407.38 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $234.42 / $407.38
| Professional | | $234.42 | $234.42 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $501.19 / $602.56
| Facility | | $398.11 | $501.19 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $251.19 / $407.38
| Facility | | $251.19 | $251.19 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $181.97 / $354.81
| Professional | | $181.97 | $181.97 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.88 / $302.00 / $323.59
| Facility | | $154.88 | $302.00 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $199.53 / $295.12
| Professional | | $134.90 | $199.53 | $295.12 |