- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $413.84 / $517.29 / $750.09
| Facility | | $413.84 | $517.29 | $750.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.29 / $517.29 / $605.00
| Professional | | $517.29 | $517.29 | $605.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.72 / $171.36 / $183.69
| Professional | | $144.72 | $171.36 | $183.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.82 / $286.19 / $519.84
| Facility | | $155.82 | $286.19 | $519.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.25 / $215.25 / $215.25
| Professional | | $215.25 | $215.25 | $215.25 |