- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.19 / $225.19 / $258.97
| Facility | | $225.19 | $225.19 | $258.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.11 / $247.62 / $281.38
| Professional | | $225.11 | $247.62 | $281.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.37 / $225.11 / $225.11
| Facility | | $212.37 | $225.11 | $225.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.11 / $225.11 / $225.11
| Professional | | $225.11 | $225.11 | $225.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $247.62 / $298.26 / $402.37
| Facility | | $247.62 | $298.26 | $402.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.11 / $225.11 / $281.39
| Professional | | $225.11 | $225.11 | $281.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.11 / $225.11 / $332.82
| Facility | | $225.11 | $225.11 | $332.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.47 / $270.13 / $270.13
| Professional | | $248.47 | $270.13 | $270.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.11 / $225.11 / $225.11
| Professional | | $225.11 | $225.11 | $225.11 |