- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $207.10 / $207.10 / $330.07
| Facility | | $207.10 | $207.10 | $330.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.49 / $236.23 / $330.07
| Professional | | $198.49 | $236.23 | $330.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $286.38 / $286.38 / $286.38
| Facility | | $286.38 | $286.38 | $286.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.38 / $286.38 / $286.38
| Professional | | $286.38 | $286.38 | $286.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.92 / $230.92 / $230.92
| Facility | | $230.92 | $230.92 | $230.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.57 / $168.57 / $230.92
| Professional | | $168.57 | $168.57 | $230.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.91 / $175.45 / $284.10
| Professional | | $122.91 | $175.45 | $284.10 |