- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.19 / $127.19 / $133.06
| Facility | | $127.19 | $127.19 | $133.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.19 / $127.19 / $182.39
| Professional | | $127.19 | $127.19 | $182.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $368.00 / $368.00 / $604.00
| Professional | | $368.00 | $368.00 | $604.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.82 / $237.82 / $525.55
| Professional | | $237.82 | $237.82 | $525.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.86 / $326.74 / $569.39
| Professional | | $160.86 | $326.74 | $569.39 |