- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.82 / $181.21 / $181.22
| Facility | | $175.82 | $181.21 | $181.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.21 / $183.03 / $201.33
| Professional | | $181.21 | $183.03 | $201.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $702.39 / $852.39 / $1,146.73
| Facility | | $702.39 | $852.39 | $1,146.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.17 / $181.22 / $181.22
| Professional | | $52.17 | $181.22 | $181.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.22 / $181.22 / $181.22
| Facility | | $181.22 | $181.22 | $181.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.22 / $181.22 / $313.23
| Professional | | $181.22 | $181.22 | $313.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.84 / $181.22 / $181.22
| Professional | | $173.84 | $181.22 | $181.22 |