- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.96 / $452.72 / $921.40
| Facility | | $181.96 | $452.72 | $921.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.45 / $182.45 / $262.36
| Professional | | $182.45 | $182.45 | $262.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.45 / $182.45 / $195.79
| Professional | | $182.45 | $182.45 | $195.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.45 / $182.45 / $232.36
| Professional | | $182.45 | $182.45 | $232.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.45 / $182.45 / $302.35
| Professional | | $182.45 | $182.45 | $302.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.45 / $182.45 / $295.70
| Professional | | $182.45 | $182.45 | $295.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.18 / $184.18 / $184.18
| Professional | | $184.18 | $184.18 | $184.18 |