- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.56 / $266.33 / $272.16
| Facility | | $177.56 | $266.33 | $272.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.56 / $177.56 / $195.31
| Professional | | $177.56 | $177.56 | $195.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.63 / $192.63 / $192.63
| Facility | | $192.63 | $192.63 | $192.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.26 / $192.63 / $192.63
| Professional | | $184.26 | $192.63 | $192.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.68 / $174.44 / $174.44
| Facility | | $141.68 | $174.44 | $174.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.44 / $174.44 / $174.44
| Professional | | $174.44 | $174.44 | $174.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.96 / $163.54 / $186.90
| Professional | | $147.96 | $163.54 | $186.90 |