- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.24 / $265.04 / $321.31
| Facility | | $159.24 | $265.04 | $321.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.30 / $266.30 / $266.30
| Professional | | $266.30 | $266.30 | $266.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.70 / $272.70 / $272.70
| Professional | | $272.70 | $272.70 | $272.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $60.00 / $72.09
| Professional | | $45.00 | $60.00 | $72.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.80 / $375.57 / $395.33
| Professional | | $304.80 | $375.57 | $395.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.37 / $267.37 / $267.37
| Professional | | $267.37 | $267.37 | $267.37 |