- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.77 / $167.77 / $193.58
| Professional | | $167.77 | $167.77 | $193.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.05 / $318.05 / $368.20
| Facility | | $318.05 | $318.05 | $368.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.98 / $212.98 / $212.98
| Facility | | $212.98 | $212.98 | $212.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.47 / $280.24 / $298.63
| Professional | | $155.47 | $280.24 | $298.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.98 / $212.98 / $212.98
| Facility | | $212.98 | $212.98 | $212.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.47 / $280.48 / $298.63
| Professional | | $155.47 | $280.48 | $298.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.91 / $203.65 / $397.44
| Professional | | $118.91 | $203.65 | $397.44 |