- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $233.03 / $233.03 / $364.11
| Facility | | $233.03 | $233.03 | $364.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.76 / $337.60 / $364.11
| Professional | | $218.76 | $337.60 | $364.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $322.25 / $322.25 / $322.25
| Facility | | $322.25 | $322.25 | $322.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.25 / $322.25 / $322.25
| Professional | | $322.25 | $322.25 | $322.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $274.52 / $274.52 / $274.52
| Facility | | $274.52 | $274.52 | $274.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.41 / $200.41 / $274.52
| Professional | | $200.41 | $200.41 | $274.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.80 / $207.45 / $318.51
| Professional | | $137.80 | $207.45 | $318.51 |