- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.48 / $208.48 / $325.75
| Facility | | $208.48 | $208.48 | $325.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.70 / $303.08 / $325.75
| Professional | | $195.70 | $303.08 | $325.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.27 / $288.27 / $288.27
| Facility | | $288.27 | $288.27 | $288.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.27 / $288.27 / $288.27
| Professional | | $288.27 | $288.27 | $288.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.35 / $239.35 / $239.35
| Facility | | $239.35 | $239.35 | $239.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.73 / $174.73 / $328.98
| Professional | | $174.73 | $174.73 | $328.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.93 / $185.59 / $254.10
| Professional | | $109.93 | $185.59 | $254.10 |