- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.09 / $181.09 / $288.61
| Facility | | $181.09 | $181.09 | $288.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.09 / $230.18 / $291.44
| Professional | | $181.09 | $230.18 | $291.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.33 / $302.33 / $302.33
| Facility | | $302.33 | $302.33 | $302.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.33 / $302.33 / $302.33
| Professional | | $302.33 | $302.33 | $302.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $278.10 / $278.10 / $278.10
| Facility | | $278.10 | $278.10 | $278.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.01 / $203.01 / $278.10
| Professional | | $203.01 | $203.01 | $278.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.16 / $206.76 / $331.86
| Professional | | $124.16 | $206.76 | $331.86 |