- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.61 / $193.61 / $308.56
| Facility | | $193.61 | $193.61 | $308.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.41 / $264.27 / $308.56
| Professional | | $193.41 | $264.27 | $308.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $267.72 / $267.72 / $267.72
| Facility | | $267.72 | $267.72 | $267.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.72 / $267.72 / $267.72
| Professional | | $267.72 | $267.72 | $267.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $215.87 / $215.87 / $215.87
| Facility | | $215.87 | $215.87 | $215.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.59 / $157.59 / $215.87
| Professional | | $157.59 | $157.59 | $215.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.90 / $164.02 / $265.60
| Professional | | $114.90 | $164.02 | $265.60 |