- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $248.64 / $248.64 / $248.64
| Facility | | $248.64 | $248.64 | $248.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.70 / $176.22 / $248.64
| Professional | | $117.70 | $176.22 | $248.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.76 / $206.76 / $330.82
| Professional | | $206.76 | $206.76 | $330.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.38 / $179.38 / $179.38
| Professional | | $179.38 | $179.38 | $179.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.00 / $142.00 / $274.19
| Facility | | $142.00 | $142.00 | $274.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.66 / $142.00 / $240.08
| Professional | | $103.66 | $142.00 | $240.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.45 / $129.46 / $191.71
| Professional | | $81.45 | $129.46 | $191.71 |