- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $215.82 / $253.36 / $259.00
| Facility | | $215.82 | $253.36 | $259.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.74 / $175.60 / $197.70
| Professional | | $165.74 | $175.60 | $197.70 |
- 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
- $128.22 / $200.94 / $263.76
| Professional | | $128.22 | $200.94 | $263.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.89 / $192.73 / $482.18
| Professional | | $167.89 | $192.73 | $482.18 |