- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.27 / $131.77 / $544.00
| Facility | | $116.27 | $131.77 | $544.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.27 / $131.77 / $251.39
| Professional | | $116.27 | $131.77 | $251.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.16 / $136.16 / $348.62
| Professional | | $136.16 | $136.16 | $348.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.47 / $183.20 / $327.55
| Professional | | $117.47 | $183.20 | $327.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.47 / $306.39 / $306.39
| Professional | | $146.47 | $306.39 | $306.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.44 / $203.92 / $329.08
| Professional | | $128.44 | $203.92 | $329.08 |