- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.02 / $264.45 / $325.68
| Facility | | $246.02 | $264.45 | $325.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.38 / $130.38 / $156.21
| Professional | | $130.38 | $130.38 | $156.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.60 / $152.00 / $249.40
| Professional | | $105.60 | $152.00 | $249.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.40 / $383.70 / $383.70
| Facility | | $115.40 | $383.70 | $383.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $391.71 / $466.06 / $466.06
| Professional | | $391.71 | $466.06 | $466.06 |