- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $233.40 / $233.40 / $364.68
| Facility | | $233.40 | $233.40 | $364.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.08 / $339.33 / $364.68
| Professional | | $219.08 | $339.33 | $364.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $322.72 / $322.72 / $322.72
| Facility | | $322.72 | $322.72 | $322.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.72 / $322.72 / $322.72
| Professional | | $322.72 | $322.72 | $322.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $267.94 / $267.94 / $267.94
| Facility | | $267.94 | $267.94 | $267.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.60 / $195.60 / $267.94
| Professional | | $195.60 | $195.60 | $267.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.07 / $207.77 / $284.45
| Professional | | $123.07 | $207.77 | $284.45 |