- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.72 / $271.42 / $594.14
| Facility | | $180.72 | $271.42 | $594.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.72 / $180.72 / $180.72
| Professional | | $180.72 | $180.72 | $180.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.22 / $180.30 / $225.00
| Professional | | $135.22 | $180.30 | $225.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.82 / $223.82 / $223.82
| Facility | | $223.82 | $223.82 | $223.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.68 / $181.68 / $181.68
| Professional | | $181.68 | $181.68 | $181.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.27 / $180.30 / $200.13
| Professional | | $162.27 | $180.30 | $200.13 |