- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.70 / $275.70 / $275.70
| Facility | | $275.70 | $275.70 | $275.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.58 / $275.70 / $288.33
| Professional | | $273.58 | $275.70 | $288.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $312.64 / $312.64 / $2,044.82
| Facility | | $312.64 | $312.64 | $2,044.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.11 / $312.64 / $312.64
| Professional | | $250.11 | $312.64 | $312.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $226.63 / $226.63 / $226.63
| Facility | | $226.63 | $226.63 | $226.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.64 / $192.64 / $192.64
| Professional | | $192.64 | $192.64 | $192.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.00 / $273.58 / $288.33
| Facility | | $90.00 | $273.58 | $288.33 |