- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.51 / $260.51 / $273.54
| Facility | | $260.51 | $260.51 | $273.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.09 / $227.94 / $260.51
| Professional | | $217.09 | $227.94 | $260.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $235.52 / $235.52 / $235.52
| Facility | | $235.52 | $235.52 | $235.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.86 / $235.52 / $235.52
| Professional | | $222.86 | $235.52 | $235.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.80 / $217.09 / $217.09
| Facility | | $204.80 | $217.09 | $217.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.09 / $217.09 / $235.52
| Professional | | $217.09 | $217.09 | $235.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.10 / $217.09 / $249.65
| Professional | | $214.10 | $217.09 | $249.65 |