- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $221.81 / $225.28 / $940.95
| Facility | | $221.81 | $225.28 | $940.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.60 / $227.42 / $353.43
| Professional | | $125.60 | $227.42 | $353.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.85 / $296.85 / $296.85
| Professional | | $296.85 | $296.85 | $296.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.70 / $306.70 / $306.70
| Facility | | $306.70 | $306.70 | $306.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.70 / $306.70 / $306.70
| Professional | | $306.70 | $306.70 | $306.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $296.00 / $296.00 / $301.92
| Facility | | $296.00 | $296.00 | $301.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.08 / $216.08 / $301.92
| Professional | | $216.08 | $216.08 | $301.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.94 / $197.46 / $312.64
| Professional | | $125.94 | $197.46 | $312.64 |