- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.71 / $175.71 / $183.92
| Facility | | $175.71 | $175.71 | $183.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.71 / $175.71 / $201.13
| Professional | | $175.71 | $175.71 | $201.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $481.00 / $481.00 / $790.00
| Professional | | $481.00 | $481.00 | $790.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.88 / $341.88 / $702.68
| Professional | | $341.88 | $341.88 | $702.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.43 / $362.08 / $700.70
| Professional | | $218.43 | $362.08 | $700.70 |