- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $185.37 / $185.37 / $187.34
| Facility | | $185.37 | $185.37 | $187.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.00 / $156.27 / $187.34
| Professional | | $141.00 | $156.27 | $187.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.29 / $227.39 / $350.05
| Professional | | $187.29 | $227.39 | $350.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.97 / $154.68 / $194.07
| Professional | | $118.97 | $154.68 | $194.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.01 / $231.40 / $292.42
| Professional | | $181.01 | $231.40 | $292.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.61 / $182.00 / $273.00
| Professional | | $140.61 | $182.00 | $273.00 |