- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.72 / $197.35 / $390.36
| Facility | | $180.72 | $197.35 | $390.36 |
- 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 / $180.30
| Professional | | $180.30 | $180.30 | $180.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.00 / $82.00 / $82.00
| Professional | | $82.00 | $82.00 | $82.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.61 / $212.61 / $275.24
| Facility | | $212.61 | $212.61 | $275.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.89 / $180.30 / $212.61
| Professional | | $174.89 | $180.30 | $212.61 |