- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $187.12 / $219.66 / $260.00
| Facility | | $187.12 | $219.66 | $260.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.11 / $156.91 / $176.39
| Professional | | $148.11 | $156.91 | $176.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $635.48 / $635.48 / $635.48
| Facility | | $635.48 | $635.48 | $635.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.96 / $210.14 / $271.31
| Professional | | $133.96 | $210.14 | $271.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.00 / $216.65 / $501.71
| Professional | | $145.00 | $216.65 | $501.71 |