- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $237.18 / $237.40 / $249.04
| Facility | | $237.18 | $237.40 | $249.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.83 / $199.81 / $237.40
| Professional | | $197.83 | $199.81 | $237.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $214.43 / $214.43 / $214.43
| Facility | | $214.43 | $214.43 | $214.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.40 / $214.43 / $214.43
| Professional | | $201.40 | $214.43 | $214.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.63 / $197.83 / $197.83
| Facility | | $186.63 | $197.83 | $197.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.83 / $197.83 / $214.63
| Professional | | $197.83 | $197.83 | $214.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.63 / $197.83 / $232.64
| Professional | | $196.63 | $197.83 | $232.64 |