- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $148.22 / $148.22 / $155.38
| Facility | | $148.22 | $148.22 | $155.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.22 / $148.22 / $168.95
| Professional | | $148.22 | $148.22 | $168.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $405.00 / $405.00 / $665.00
| Professional | | $405.00 | $405.00 | $665.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.37 / $286.37 / $589.29
| Professional | | $286.37 | $286.37 | $589.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.95 / $302.57 / $551.09
| Professional | | $179.95 | $302.57 | $551.09 |