- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.86 / $239.86 / $239.86
| Facility | | $239.86 | $239.86 | $239.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.86 / $239.86 / $323.81
| Professional | | $239.86 | $239.86 | $323.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.09 / $177.29 / $238.52
| Facility | | $146.09 | $177.29 | $238.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.16 / $235.16 / $235.16
| Professional | | $235.16 | $235.16 | $235.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.38 / $263.38 / $263.38
| Facility | | $263.38 | $263.38 | $263.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.41 / $263.38 / $263.38
| Professional | | $226.41 | $263.38 | $263.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.16 / $265.73 / $282.19
| Professional | | $235.16 | $265.73 | $282.19 |