- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.87 / $139.25 / $233.94
| Facility | | $122.87 | $139.25 | $233.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.87 / $139.25 / $163.82
| Professional | | $122.87 | $139.25 | $163.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.74 / $182.76 / $208.24
| Professional | | $124.74 | $182.76 | $208.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.19 / $154.10 / $252.57
| Professional | | $126.19 | $154.10 | $252.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.00 / $186.45 / $227.81
| Professional | | $115.00 | $186.45 | $227.81 |