- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.70 / $235.52 / $403.72
| Facility | | $193.70 | $235.52 | $403.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.81 / $219.82 / $241.80
| Professional | | $219.81 | $219.82 | $241.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $215.51 / $215.51 / $215.51
| Facility | | $215.51 | $215.51 | $215.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.51 / $215.51 / $215.51
| Professional | | $215.51 | $215.51 | $215.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.45 / $241.37 / $241.37
| Facility | | $181.45 | $241.37 | $241.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.37 / $241.37 / $241.37
| Professional | | $241.37 | $241.37 | $241.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.73 / $215.51 / $258.61
| Professional | | $204.73 | $215.51 | $258.61 |