- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $242.71 / $292.31 / $292.31
| Facility | | $242.71 | $292.31 | $292.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.71 / $242.71 / $292.31
| Professional | | $242.71 | $242.71 | $292.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.22 / $141.22 / $234.42
| Professional | | $141.22 | $141.22 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.68 / $127.68 / $248.98
| Professional | | $127.68 | $127.68 | $248.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.39 / $263.39 / $263.39
| Facility | | $263.39 | $263.39 | $263.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.04 / $116.04 / $116.04
| Professional | | $116.04 | $116.04 | $116.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $242.71 / $292.31 / $447.23
| Facility | | $242.71 | $292.31 | $447.23 |