- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $149.36 / $149.36 / $155.46
| Facility | | $149.36 | $149.36 | $155.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.74 / $124.75 / $268.67
| Professional | | $114.74 | $124.75 | $268.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.00 / $644.00 / $644.00
| Professional | | $392.00 | $644.00 | $644.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.76 / $287.23 / $481.86
| Professional | | $212.76 | $287.23 | $481.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.80 / $320.39 / $744.70
| Professional | | $235.80 | $320.39 | $744.70 |