- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $224.33 / $224.33 / $357.53
| Facility | | $224.33 | $224.33 | $357.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.16 / $255.88 / $357.53
| Professional | | $216.16 | $255.88 | $357.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $310.20 / $310.20 / $310.20
| Facility | | $310.20 | $310.20 | $310.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.20 / $310.20 / $310.20
| Professional | | $310.20 | $310.20 | $310.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.60 / $252.60 / $252.60
| Facility | | $252.60 | $252.60 | $252.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.40 / $184.40 / $375.44
| Professional | | $184.40 | $184.40 | $375.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.13 / $186.23 / $307.75
| Professional | | $133.13 | $186.23 | $307.75 |