- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $270.12 / $270.12 / $422.06
| Facility | | $270.12 | $270.12 | $422.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.12 / $422.06 / $472.75
| Professional | | $270.12 | $422.06 | $472.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $373.51 / $373.51 / $373.51
| Facility | | $373.51 | $373.51 | $373.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.51 / $373.51 / $373.51
| Professional | | $373.51 | $373.51 | $373.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $365.10 / $365.10 / $365.10
| Facility | | $365.10 | $365.10 | $365.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.52 / $266.52 / $365.10
| Professional | | $266.52 | $266.52 | $365.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.31 / $240.46 / $380.35
| Professional | | $160.31 | $240.46 | $380.35 |