- 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
- $203.29 / $239.86 / $263.83
| Professional | | $203.29 | $239.86 | $263.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $727.09 / $727.09 / $727.09
| Facility | | $727.09 | $727.09 | $727.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.45 / $228.45 / $235.16
| Professional | | $228.45 | $228.45 | $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
- $263.38 / $263.38 / $263.38
| Professional | | $263.38 | $263.38 | $263.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.86 / $277.52 / $425.73
| Professional | | $239.86 | $277.52 | $425.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.29 / $239.86 / $467.72
| Professional | | $203.29 | $239.86 | $467.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.16 / $235.16 / $352.74
| Professional | | $235.16 | $235.16 | $352.74 |