- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $358.05 / $358.05 / $408.18
| Facility | | $358.05 | $358.05 | $408.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.00 / $154.28 / $274.80
| Professional | | $115.00 | $154.28 | $274.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.00 / $265.00 / $310.00
| Professional | | $215.00 | $265.00 | $310.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.13 / $133.00 / $227.03
| Professional | | $94.13 | $133.00 | $227.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.04 / $159.46 / $270.24
| Professional | | $130.04 | $159.46 | $270.24 |