- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.35 / $197.51 / $230.24
| Facility | | $193.35 | $197.51 | $230.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.59 / $182.85 / $201.76
| Professional | | $164.59 | $182.85 | $201.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.40 / $182.40 / $182.40
| Facility | | $182.40 | $182.40 | $182.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.46 / $182.40 / $182.40
| Professional | | $169.46 | $182.40 | $182.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.27 / $164.59 / $175.43
| Facility | | $155.27 | $164.59 | $175.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.59 / $164.59 / $164.59
| Professional | | $164.59 | $164.59 | $164.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.59 / $164.59 / $198.67
| Professional | | $164.59 | $164.59 | $198.67 |