- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $197.65 / $272.76 / $604.85
| Facility | | $197.65 | $272.76 | $604.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.83 / $197.83 / $237.40
| Professional | | $197.83 | $197.83 | $237.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.72 / $195.72 / $293.58
| Facility | | $195.72 | $195.72 | $293.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.72 / $195.72 / $199.63
| Professional | | $195.72 | $195.72 | $199.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.63 / $186.63 / $197.83
| Facility | | $186.63 | $186.63 | $197.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.83 / $197.83 / $197.83
| Professional | | $197.83 | $197.83 | $197.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $236.78 / $236.78 / $236.78
| Facility | | $236.78 | $236.78 | $236.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.05 / $197.83 / $231.33
| Professional | | $178.05 | $197.83 | $231.33 |