- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.13 / $265.91 / $580.85
| Facility | | $206.13 | $265.91 | $580.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.13 / $207.13 / $248.55
| Professional | | $207.13 | $207.13 | $248.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.32 / $157.60 / $225.54
| Facility | | $134.32 | $157.60 | $225.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.54 / $225.54 / $230.05
| Professional | | $225.54 | $225.54 | $230.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.40 / $195.40 / $207.13
| Facility | | $195.40 | $195.40 | $207.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.13 / $207.13 / $207.13
| Professional | | $207.13 | $207.13 | $207.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.81 / $207.13 / $252.70
| Professional | | $196.81 | $207.13 | $252.70 |