- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $214.84 / $245.53 / $246.33
| Facility | | $214.84 | $245.53 | $246.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.61 / $214.84 / $245.53
| Professional | | $204.61 | $214.84 | $245.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.53 / $176.53 / $176.53
| Facility | | $176.53 | $176.53 | $176.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.61 / $204.61 / $221.38
| Facility | | $204.61 | $204.61 | $221.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.06 / $204.61 / $204.61
| Professional | | $200.06 | $204.61 | $204.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.15 / $204.61 / $265.99
| Professional | | $184.15 | $204.61 | $265.99 |