- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.09 / $170.09 / $212.61
| Facility | | $170.09 | $170.09 | $212.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.09 / $170.09 / $212.61
| Professional | | $170.09 | $170.09 | $212.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $215.06 / $253.01 / $293.33
| Facility | | $215.06 | $253.01 | $293.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.61 / $212.61 / $212.61
| Professional | | $212.61 | $212.61 | $212.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.09 / $212.61 / $253.76
| Facility | | $170.09 | $212.61 | $253.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.30 / $180.30 / $208.36
| Professional | | $180.30 | $180.30 | $208.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.30 / $180.30 / $212.61
| Professional | | $180.30 | $180.30 | $212.61 |