- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $320.39 / $320.39 / $560.70
| Facility | | $320.39 | $320.39 | $560.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.18 / $320.39 / $320.39
| Professional | | $253.18 | $320.39 | $320.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.20 / $172.20 / $172.20
| Professional | | $172.20 | $172.20 | $172.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $247.20 / $247.20 / $247.20
| Facility | | $247.20 | $247.20 | $247.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.76 / $205.76 / $205.76
| Professional | | $205.76 | $205.76 | $205.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.89 / $284.89 / $284.89
| Professional | | $284.89 | $284.89 | $284.89 |