- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.55 / $229.58 / $376.69
| Facility | | $171.55 | $229.58 | $376.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.55 / $251.05 / $376.69
| Professional | | $171.55 | $251.05 | $376.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.00 / $268.00 / $268.00
| Professional | | $268.00 | $268.00 | $268.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.01 / $265.89 / $386.03
| Professional | | $117.01 | $265.89 | $386.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.84 / $236.35 / $401.25
| Professional | | $166.84 | $236.35 | $401.25 |