- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.07 / $223.07 / $348.55
| Facility | | $223.07 | $223.07 | $348.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.07 / $348.55 / $396.44
| Professional | | $223.07 | $348.55 | $396.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.45 / $308.45 / $308.45
| Facility | | $308.45 | $308.45 | $308.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.45 / $308.45 / $308.45
| Professional | | $308.45 | $308.45 | $308.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.16 / $306.16 / $306.16
| Facility | | $306.16 | $306.16 | $306.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.50 / $223.50 / $306.16
| Professional | | $223.50 | $223.50 | $306.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.38 / $198.59 / $314.10
| Professional | | $132.38 | $198.59 | $314.10 |