- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $304.48 / $304.48 / $309.86
| Facility | | $304.48 | $304.48 | $309.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.07 / $271.27 / $309.86
| Professional | | $208.07 | $271.27 | $309.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.49 / $270.49 / $270.49
| Professional | | $270.49 | $270.49 | $270.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $674.40 / $818.42 / $1,101.04
| Facility | | $674.40 | $818.42 | $1,101.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.70 / $272.27 / $317.33
| Professional | | $180.70 | $272.27 | $317.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.96 / $272.70 / $396.21
| Professional | | $227.96 | $272.70 | $396.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.18 / $251.70 / $397.69
| Professional | | $185.18 | $251.70 | $397.69 |