- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.09 / $175.17 / $177.26
| Facility | | $173.09 | $175.17 | $177.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.83 / $173.09 / $177.26
| Professional | | $166.83 | $173.09 | $177.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.76 / $205.69 / $348.01
| Facility | | $172.76 | $205.69 | $348.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.41 / $166.84 / $190.57
| Professional | | $156.41 | $166.84 | $190.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.26 / $177.26 / $177.26
| Facility | | $177.26 | $177.26 | $177.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.26 / $177.26 / $177.26
| Professional | | $177.26 | $177.26 | $177.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.67 / $675.67 / $675.67
| Professional | | $675.67 | $675.67 | $675.67 |