- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $227.49 / $425.22 / $637.83
| Facility | | $227.49 | $425.22 | $637.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.21 / $172.21 / $206.65
| Professional | | $172.21 | $172.21 | $206.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.30 / $180.30 / $180.30
| Facility | | $180.30 | $180.30 | $180.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.37 / $212.61 / $246.26
| Facility | | $184.37 | $212.61 | $246.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.30 / $180.30 / $180.30
| Professional | | $180.30 | $180.30 | $180.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.30 / $180.30 / $180.30
| Professional | | $180.30 | $180.30 | $180.30 |