- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.31 / $269.31 / $269.31
| Facility | | $269.31 | $269.31 | $269.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.49 / $269.31 / $269.31
| Professional | | $127.49 | $269.31 | $269.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.00 / $294.00 / $294.00
| Professional | | $294.00 | $294.00 | $294.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $194.98 / $194.98
| Professional | | $194.98 | $194.98 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.00 / $175.00 / $296.95
| Facility | | $175.00 | $175.00 | $296.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.75 / $175.00 / $284.22
| Professional | | $127.75 | $175.00 | $284.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $300.68 / $300.68 / $353.74
| Facility | | $300.68 | $300.68 | $353.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.24 / $132.35 / $202.54
| Professional | | $88.24 | $132.35 | $202.54 |