- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.09 / $173.09 / $302.91
| Facility | | $173.09 | $173.09 | $302.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.83 / $173.09 / $177.26
| Professional | | $166.83 | $173.09 | $177.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.26 / $177.26 / $177.26
| Facility | | $177.26 | $177.26 | $177.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.26 / $177.26 / $177.26
| Professional | | $177.26 | $177.26 | $177.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $198.11 / $417.08 / $782.03
| Facility | | $198.11 | $417.08 | $782.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $792.45 / $792.45 / $938.43
| Professional | | $792.45 | $792.45 | $938.43 |