- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.28 / $210.98 / $217.47
| Facility | | $190.28 | $210.98 | $217.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.21 / $190.28 / $217.47
| Professional | | $181.21 | $190.28 | $217.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.19 / $140.19 / $140.19
| Facility | | $140.19 | $140.19 | $140.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.71 / $181.22 / $181.22
| Facility | | $175.71 | $181.22 | $181.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.22 / $181.22 / $181.22
| Professional | | $181.22 | $181.22 | $181.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $149.82 / $149.82 / $149.82
| Facility | | $149.82 | $149.82 | $149.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.32 / $181.22 / $243.08
| Professional | | $171.32 | $181.22 | $243.08 |