- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.08 / $176.08 / $176.08
| Facility | | $176.08 | $176.08 | $176.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.25 / $176.08 / $212.66
| Professional | | $163.25 | $176.08 | $212.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.46 / $270.48 / $766.08
| Professional | | $229.46 | $270.48 | $766.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.44 / $284.72 / $766.08
| Professional | | $155.44 | $284.72 | $766.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.10 / $286.97 / $483.86
| Professional | | $179.10 | $286.97 | $483.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.28 / $279.27 / $883.45
| Professional | | $185.28 | $279.27 | $883.45 |