- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $237.75 / $237.75 / $237.75
| Facility | | $237.75 | $237.75 | $237.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.96 / $225.45 / $256.19
| Professional | | $204.96 | $225.45 | $256.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.33 / $347.82 / $525.91
| Facility | | $306.33 | $347.82 | $525.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.96 / $204.96 / $204.96
| Professional | | $204.96 | $204.96 | $204.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $204.10 / $1,158.83
| Professional | | $60.00 | $204.10 | $1,158.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.91 / $225.45 / $225.45
| Professional | | $202.91 | $225.45 | $225.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.96 / $204.96 / $204.96
| Professional | | $204.96 | $204.96 | $204.96 |