- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.61 / $243.61 / $380.64
| Facility | | $243.61 | $243.61 | $380.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.68 / $364.10 / $472.28
| Professional | | $228.68 | $364.10 | $472.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.02 / $326.02 / $347.76
| Professional | | $326.02 | $326.02 | $347.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $413.75 / $413.75 / $413.75
| Facility | | $413.75 | $413.75 | $413.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $413.75 / $413.75 / $413.75
| Professional | | $413.75 | $413.75 | $413.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.20 / $281.20 / $281.20
| Facility | | $281.20 | $281.20 | $281.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.28 / $205.28 / $281.20
| Professional | | $205.28 | $205.28 | $281.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.58 / $216.86 / $343.02
| Professional | | $144.58 | $216.86 | $343.02 |