- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $148.35 / $148.35 / $148.35
| Facility | | $148.35 | $148.35 | $148.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.35 / $162.00 / $162.00
| Professional | | $148.35 | $162.00 | $162.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $183.05 / $404.21 / $496.55
| Facility | | $183.05 | $404.21 | $496.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.47 / $194.26 / $757.70
| Professional | | $119.47 | $194.26 | $757.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.94 / $141.62 / $257.94
| Professional | | $98.94 | $141.62 | $257.94 |