- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $185.27 / $185.27 / $185.27
| Facility | | $185.27 | $185.27 | $185.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.27 / $219.40 / $278.27
| Professional | | $185.27 | $219.40 | $278.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.64 / $311.77 / $504.16
| Facility | | $306.64 | $311.77 | $504.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.60 / $227.60 / $441.45
| Professional | | $227.60 | $227.60 | $441.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.58 / $463.83 / $660.45
| Professional | | $460.58 | $463.83 | $660.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.11 / $504.16 / $504.16
| Professional | | $461.11 | $504.16 | $504.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.23 / $265.20 / $504.16
| Professional | | $219.23 | $265.20 | $504.16 |