- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.54 / $172.54 / $269.58
| Facility | | $172.54 | $172.54 | $269.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.54 / $269.58 / $343.84
| Professional | | $172.54 | $269.58 | $343.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.58 / $238.58 / $238.58
| Facility | | $238.58 | $238.58 | $238.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.58 / $238.58 / $238.58
| Professional | | $238.58 | $238.58 | $238.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $265.56 / $265.56 / $265.56
| Facility | | $265.56 | $265.56 | $265.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.86 / $193.86 / $265.56
| Professional | | $193.86 | $193.86 | $265.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.40 / $153.60 / $236.69
| Professional | | $102.40 | $153.60 | $236.69 |