- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $282.27 / $282.27 / $282.27
| Facility | | $282.27 | $282.27 | $282.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.27 / $282.27 / $282.27
| Professional | | $282.27 | $282.27 | $282.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.35 / $205.88 / $236.77
| Facility | | $182.35 | $205.88 | $236.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.08 / $289.08 / $289.08
| Professional | | $289.08 | $289.08 | $289.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $256.22 / $328.97 / $458.66
| Facility | | $256.22 | $328.97 | $458.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.25 / $283.42 / $283.42
| Professional | | $269.25 | $283.42 | $283.42 |