- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.97 / $217.46 / $315.32
| Facility | | $173.97 | $217.46 | $315.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.70 / $217.46 / $217.46
| Professional | | $167.70 | $217.46 | $217.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.28 / $54.28 / $171.36
| Professional | | $54.28 | $54.28 | $171.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $82.83 / $246.33 / $449.55
| Facility | | $82.83 | $246.33 | $449.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.24 / $215.25 / $216.00
| Professional | | $40.24 | $215.25 | $216.00 |