- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $215.72 / $215.72 / $226.03
| Facility | | $215.72 | $215.72 | $226.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.72 / $215.72 / $240.42
| Professional | | $215.72 | $215.72 | $240.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $589.00 / $589.00 / $968.00
| Professional | | $589.00 | $589.00 | $968.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.13 / $329.13 / $696.54
| Professional | | $329.13 | $329.13 | $696.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.70 / $425.31 / $742.71
| Professional | | $216.70 | $425.31 | $742.71 |