- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $305.64 / $305.64 / $305.64
| Facility | | $305.64 | $305.64 | $305.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.04 / $305.64 / $305.64
| Professional | | $296.04 | $305.64 | $305.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $400.51 / $425.26 / $811.15
| Facility | | $400.51 | $425.26 | $811.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.57 / $315.14 / $507.93
| Professional | | $270.57 | $315.14 | $507.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.31 / $370.63 / $1,247.23
| Facility | | $303.31 | $370.63 | $1,247.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.31 / $333.56 / $624.24
| Professional | | $303.31 | $333.56 | $624.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.57 / $358.70 / $483.74
| Professional | | $270.57 | $358.70 | $483.74 |