- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $248.61 / $281.76 / $361.62
| Facility | | $248.61 | $281.76 | $361.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.72 / $159.72 / $159.72
| Professional | | $159.72 | $159.72 | $159.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $361.62 / $361.62 / $361.62
| Professional | | $361.62 | $361.62 | $361.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.35 / $315.55 / $376.69
| Professional | | $301.35 | $315.55 | $376.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.49 / $361.62 / $421.89
| Professional | | $331.49 | $361.62 | $421.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.35 / $452.03 / $452.03
| Professional | | $301.35 | $452.03 | $452.03 |