- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.16 / $162.97 / $247.70
| Facility | | $156.16 | $162.97 | $247.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.97 / $162.97 / $196.09
| Professional | | $162.97 | $162.97 | $196.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $185.00 / $272.99 / $503.64
| Facility | | $185.00 | $272.99 | $503.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.28 / $173.28 / $210.41
| Professional | | $173.28 | $173.28 | $210.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.75 / $203.81 / $203.81
| Facility | | $153.75 | $203.81 | $203.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.81 / $203.81 / $203.81
| Professional | | $203.81 | $203.81 | $203.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.97 / $187.43 / $218.36
| Professional | | $162.97 | $187.43 | $218.36 |