- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.72 / $180.72 / $243.53
| Facility | | $180.72 | $180.72 | $243.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.47 / $180.72 / $211.76
| Professional | | $176.47 | $180.72 | $211.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.72 / $191.56 / $233.87
| Facility | | $180.72 | $191.56 | $233.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.98 / $201.98 / $201.98
| Professional | | $201.98 | $201.98 | $201.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.30 / $180.30 / $234.39
| Professional | | $180.30 | $180.30 | $234.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.61 / $212.61 / $212.61
| Facility | | $212.61 | $212.61 | $212.61 |