- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.71 / $230.87 / $296.30
| Facility | | $203.71 | $230.87 | $296.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.30 / $296.30 / $296.30
| Professional | | $296.30 | $296.30 | $296.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.57 / $278.32 / $332.25
| Professional | | $236.57 | $278.32 | $332.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.92 / $296.30 / $370.38
| Professional | | $246.92 | $296.30 | $370.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.71 / $296.30 / $370.38
| Professional | | $103.71 | $296.30 | $370.38 |