- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.09 / $170.09 / $382.70
| Facility | | $170.09 | $170.09 | $382.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.09 / $212.61 / $212.61
| Professional | | $170.09 | $212.61 | $212.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.38 / $186.38 / $232.97
| Professional | | $186.38 | $186.38 | $232.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.09 / $212.61 / $289.14
| Facility | | $170.09 | $212.61 | $289.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.30 / $180.30 / $195.81
| Professional | | $180.30 | $180.30 | $195.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.26 / $180.30 / $201.94
| Professional | | $153.26 | $180.30 | $201.94 |