- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.65 / $446.65 / $446.65
| Facility | | $446.65 | $446.65 | $446.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $174.55 / $446.65
| Professional | | $161.62 | $174.55 | $446.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.47 / $152.47 / $161.62
| Facility | | $152.47 | $152.47 | $161.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $161.62
| Professional | | $161.62 | $161.62 | $161.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $168.13 / $250.83 / $428.63
| Facility | | $168.13 | $250.83 | $428.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.84 / $164.84 / $1,697.27
| Professional | | $164.84 | $164.84 | $1,697.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $234.35
| Professional | | $161.62 | $161.62 | $234.35 |