- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $241.66 / $276.18 / $276.31
| Facility | | $241.66 | $276.18 | $276.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.15 / $241.66 / $310.70
| Professional | | $230.15 | $241.66 | $310.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $209.55 / $209.55 / $210.00
| Facility | | $209.55 | $209.55 | $210.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.59 / $230.15 / $230.15
| Facility | | $167.59 | $230.15 | $230.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.15 / $230.15 / $230.15
| Professional | | $230.15 | $230.15 | $230.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.94 / $230.15 / $294.58
| Professional | | $220.94 | $230.15 | $294.58 |