- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.15 / $262.60 / $446.42
| Facility | | $243.15 | $262.60 | $446.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.04 / $263.10 / $263.10
| Professional | | $246.04 | $263.10 | $263.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.82 / $229.82 / $243.61
| Facility | | $229.82 | $229.82 | $243.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.61 / $243.61 / $243.61
| Professional | | $243.61 | $243.61 | $243.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $219.45 / $262.60 / $1,178.84
| Facility | | $219.45 | $262.60 | $1,178.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.40 / $243.15 / $243.15
| Professional | | $200.40 | $243.15 | $243.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.07 / $243.61 / $243.61
| Professional | | $207.07 | $243.61 | $243.61 |