- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.76 / $535.10 / $721.05
| Facility | | $193.76 | $535.10 | $721.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.76 / $193.76 / $193.76
| Professional | | $193.76 | $193.76 | $193.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.75 / $284.33 / $480.77
| Professional | | $189.75 | $284.33 | $480.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.79 / $182.79 / $193.76
| Facility | | $182.79 | $182.79 | $193.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.70 / $164.70 / $193.76
| Professional | | $164.70 | $164.70 | $193.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.76 / $193.76 / $314.04
| Professional | | $193.76 | $193.76 | $314.04 |