- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.07 / $165.07 / $264.48
| Facility | | $165.07 | $165.07 | $264.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.39 / $165.07 / $211.36
| Professional | | $101.39 | $165.07 | $211.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.07 / $181.58 / $4,042.45
| Facility | | $165.07 | $181.58 | $4,042.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.54 / $213.48 / $430.72
| Professional | | $175.54 | $213.48 | $430.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.76 / $197.51 / $329.13
| Professional | | $164.76 | $197.51 | $329.13 |