- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.06 / $170.48 / $170.48
| Facility | | $167.06 | $170.48 | $170.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.48 / $170.48 / $287.35
| Professional | | $170.48 | $170.48 | $287.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $702.39 / $852.39 / $1,146.73
| Facility | | $702.39 | $852.39 | $1,146.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.48 / $170.48 / $414.16
| Professional | | $170.48 | $170.48 | $414.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.48 / $170.48 / $170.48
| Facility | | $170.48 | $170.48 | $170.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.48 / $170.48 / $677.95
| Professional | | $170.48 | $170.48 | $677.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.47 / $170.48 / $170.48
| Professional | | $162.47 | $170.48 | $170.48 |