- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $285.20 / $285.20 / $733.37
| Facility | | $285.20 | $285.20 | $733.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.20 / $285.20 / $285.20
| Professional | | $285.20 | $285.20 | $285.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.29 / $820.97 / $916.72
| Professional | | $613.29 | $820.97 | $916.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $468.34 / $468.34 / $687.55
| Professional | | $468.34 | $468.34 | $687.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $244.46 / $309.64 / $733.37
| Facility | | $244.46 | $309.64 | $733.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.79 / $488.92 / $814.86
| Professional | | $207.79 | $488.92 | $814.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.12 / $407.43 / $590.77
| Professional | | $171.12 | $407.43 | $590.77 |