- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $86.63 / $239.86 / $239.86
| Facility | | $86.63 | $239.86 | $239.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.86 / $239.86 / $263.83
| Professional | | $239.86 | $239.86 | $263.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.66 / $140.66 / $140.66
| Facility | | $140.66 | $140.66 | $140.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.66 / $140.66 / $140.66
| Professional | | $140.66 | $140.66 | $140.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.54 / $263.38 / $263.38
| Facility | | $157.54 | $263.38 | $263.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.38 / $263.38 / $263.38
| Professional | | $263.38 | $263.38 | $263.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.40 / $246.92 / $282.19
| Professional | | $223.40 | $246.92 | $282.19 |