- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.24 / $206.24 / $322.25
| Facility | | $206.24 | $206.24 | $322.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.24 / $320.48 / $378.70
| Professional | | $206.24 | $320.48 | $378.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $285.18 / $285.18 / $285.18
| Facility | | $285.18 | $285.18 | $285.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.18 / $285.18 / $285.18
| Professional | | $285.18 | $285.18 | $285.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $292.48 / $292.48 / $292.48
| Facility | | $292.48 | $292.48 | $292.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.51 / $213.51 / $292.48
| Professional | | $213.51 | $213.51 | $292.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.04 / $183.60 / $279.77
| Professional | | $121.04 | $183.60 | $279.77 |