- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.60 / $193.60 / $308.55
| Facility | | $193.60 | $193.60 | $308.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.74 / $220.83 / $308.55
| Professional | | $181.74 | $220.83 | $308.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $267.70 / $267.70 / $267.70
| Facility | | $267.70 | $267.70 | $267.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.70 / $267.70 / $267.70
| Professional | | $267.70 | $267.70 | $267.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.25 / $192.25 / $192.25
| Facility | | $192.25 | $192.25 | $192.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.34 / $140.34 / $192.25
| Professional | | $140.34 | $140.34 | $192.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $164.01 / $257.27
| Professional | | $102.33 | $164.01 | $257.27 |