- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.05 / $288.05 / $401.62
| Facility | | $288.05 | $288.05 | $401.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.39 / $401.62 / $401.62
| Professional | | $289.39 | $401.62 | $401.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.00 / $117.71 / $158.36
| Facility | | $97.00 | $117.71 | $158.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.23 / $192.23 / $245.77
| Professional | | $192.23 | $192.23 | $245.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.76 / $132.22 / $340.36
| Facility | | $39.76 | $132.22 | $340.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.01 / $280.01 / $350.02
| Professional | | $280.01 | $280.01 | $350.02 |