- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $493.26 / $493.26 / $531.53
| Facility | | $493.26 | $493.26 | $531.53 |
- 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
- $180.30 / $180.30 / $198.00
| Professional | | $180.30 | $180.30 | $198.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $493.26 / $493.26 / $531.53
| Facility | | $493.26 | $493.26 | $531.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.72 / $180.72 / $531.53
| Professional | | $180.72 | $180.72 | $531.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.30 / $180.30 / $261.44
| Professional | | $180.30 | $180.30 | $261.44 |