- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $205.28 / $221.70 / $376.89
| Facility | | $205.28 | $221.70 | $376.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.65 / $220.97 / $220.98
| Professional | | $206.65 | $220.97 | $220.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.03 / $193.03 / $204.61
| Facility | | $193.03 | $193.03 | $204.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.06 / $204.61 / $209.10
| Professional | | $200.06 | $204.61 | $209.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $197.30 / $215.54 / $1,026.20
| Facility | | $197.30 | $215.54 | $1,026.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.45 / $205.28 / $205.28
| Professional | | $174.45 | $205.28 | $205.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.22 / $204.61 / $204.61
| Professional | | $143.22 | $204.61 | $204.61 |