- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.26 / $177.26 / $2,872.79
| Facility | | $177.26 | $177.26 | $2,872.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.83 / $177.26 / $177.26
| Professional | | $166.83 | $177.26 | $177.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.81 / $166.84 / $179.03
| Professional | | $141.81 | $166.84 | $179.03 |
- 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
- $177.26 / $187.90 / $299.57
| Facility | | $177.26 | $187.90 | $299.57 |