- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.93 / $161.91 / $228.00
| Facility | | $137.93 | $161.91 | $228.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.26 / $108.35 / $121.51
| Professional | | $102.26 | $108.35 | $121.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $635.48 / $635.48 / $635.48
| Facility | | $635.48 | $635.48 | $635.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.97 / $157.97 / $206.68
| Professional | | $98.97 | $157.97 | $206.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.56 / $170.30 / $290.31
| Professional | | $110.56 | $170.30 | $290.31 |