- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.38 / $140.38 / $174.70
| Facility | | $140.38 | $140.38 | $174.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.21 / $161.91 / $214.23
| Professional | | $122.21 | $161.91 | $214.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $525.00 / $525.00 / $525.00
| Facility | | $525.00 | $525.00 | $525.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.66 / $179.58 / $315.52
| Professional | | $134.66 | $179.58 | $315.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.66 / $206.13 / $374.97
| Professional | | $134.66 | $206.13 | $374.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.44 / $240.94 / $727.34
| Professional | | $206.44 | $240.94 | $727.34 |