- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.03 / $265.57 / $482.54
| Facility | | $204.03 | $265.57 | $482.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.46 / $238.46 / $286.14
| Professional | | $210.46 | $238.46 | $286.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.46 / $392.67 / $763.07
| Facility | | $238.46 | $392.67 | $763.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.46 / $238.46 / $302.83
| Professional | | $238.46 | $238.46 | $302.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $224.96 / $238.46 / $280.85
| Facility | | $224.96 | $238.46 | $280.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.46 / $238.46 / $247.45
| Professional | | $238.46 | $238.46 | $247.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.63 / $177.63 / $1,722.02
| Facility | | $177.63 | $177.63 | $1,722.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.46 / $252.77 / $306.38
| Professional | | $238.46 | $252.77 | $306.38 |