- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $198.56 / $198.56 / $198.56
| Facility | | $198.56 | $198.56 | $198.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.56 / $267.50 / $267.50
| Professional | | $198.56 | $267.50 | $267.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.19 / $301.72 / $309.23
| Professional | | $255.19 | $301.72 | $309.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.13 / $373.83 / $470.06
| Professional | | $370.13 | $373.83 | $470.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.53 / $233.78 / $1,456.51
| Facility | | $126.53 | $233.78 | $1,456.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.73 / $204.24 / $226.93
| Professional | | $108.73 | $204.24 | $226.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.77 / $204.24 / $226.93
| Professional | | $90.77 | $204.24 | $226.93 |