- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.09 / $176.47 / $465.62
| Facility | | $170.09 | $176.47 | $465.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.09 / $176.47 / $180.72
| Professional | | $170.09 | $176.47 | $180.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.30 / $187.51 / $187.51
| Facility | | $180.30 | $187.51 | $187.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.61 / $212.61 / $212.61
| Professional | | $212.61 | $212.61 | $212.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.30 / $180.30 / $212.61
| Professional | | $180.30 | $180.30 | $212.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.30 / $180.30 / $180.30
| Professional | | $180.30 | $180.30 | $180.30 |