- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.91 / $165.91 / $173.85
| Facility | | $165.91 | $165.91 | $173.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.91 / $165.91 / $206.10
| Professional | | $165.91 | $165.91 | $206.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.00 / $503.00 / $826.00
| Professional | | $503.00 | $503.00 | $826.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.68 / $242.68 / $479.31
| Professional | | $242.68 | $242.68 | $479.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.16 / $347.20 / $569.39
| Professional | | $150.16 | $347.20 | $569.39 |