- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $211.34 / $211.34 / $603.46
| Facility | | $211.34 | $211.34 | $603.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.34 / $211.34 / $211.34
| Professional | | $211.34 | $211.34 | $211.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $222.48 / $347.26 / $621.44
| Facility | | $222.48 | $347.26 | $621.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.47 / $211.47 / $211.47
| Professional | | $211.47 | $211.47 | $211.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $232.20 / $232.20 / $232.20
| Facility | | $232.20 | $232.20 | $232.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.20 / $232.20 / $232.20
| Professional | | $232.20 | $232.20 | $232.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.77 / $223.77 / $223.77
| Facility | | $223.77 | $223.77 | $223.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.77 / $248.63 / $248.63
| Professional | | $223.77 | $248.63 | $248.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.32 / $207.32 / $228.74
| Professional | | $207.32 | $207.32 | $228.74 |