- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $163.41 / $163.41 / $170.89
| Facility | | $163.41 | $163.41 | $170.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.41 / $163.41 / $185.91
| Professional | | $163.41 | $163.41 | $185.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.00 / $446.00 / $732.00
| Professional | | $446.00 | $446.00 | $732.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.89 / $297.89 / $601.85
| Professional | | $297.89 | $297.89 | $601.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.53 / $372.01 / $671.28
| Professional | | $191.53 | $372.01 | $671.28 |