- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.00 / $210.75 / $210.75
| Facility | | $174.00 | $210.75 | $210.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.19 / $145.35 / $164.03
| Professional | | $137.19 | $145.35 | $164.03 |
- 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
- $96.25 / $144.25 / $216.08
| Professional | | $96.25 | $144.25 | $216.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.56 / $156.09 / $397.19
| Professional | | $96.56 | $156.09 | $397.19 |