- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.46 / $203.46 / $203.46
| Facility | | $203.46 | $203.46 | $203.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.55 / $223.25 / $275.00
| Professional | | $192.55 | $223.25 | $275.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.98 / $101.98 / $101.98
| Facility | | $101.98 | $101.98 | $101.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.00 / $225.00 / $275.00
| Professional | | $225.00 | $225.00 | $275.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.31 / $238.84 / $311.54
| Professional | | $197.31 | $238.84 | $311.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.45 / $182.38 / $345.78
| Professional | | $101.45 | $182.38 | $345.78 |