- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.71 / $760.72 / $926.52
| Facility | | $243.71 | $760.72 | $926.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.71 / $243.71 / $334.68
| Professional | | $243.71 | $243.71 | $334.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.61 / $243.82 / $285.22
| Professional | | $243.61 | $243.82 | $285.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.92 / $229.92 / $243.71
| Facility | | $229.92 | $229.92 | $243.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.71 / $243.71 / $310.39
| Professional | | $243.71 | $243.71 | $310.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.15 / $230.98 / $259.86
| Professional | | $207.15 | $230.98 | $259.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.71 / $271.30 / $358.75
| Professional | | $243.71 | $271.30 | $358.75 |