- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.06 / $126.80 / $145.49
| Facility | | $122.06 | $126.80 | $145.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.87 / $127.56 / $152.40
| Professional | | $116.87 | $127.56 | $152.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $583.95 / $1,262.40 / $3,604.40
| Facility | | $583.95 | $1,262.40 | $3,604.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.30 / $177.00 / $235.66
| Professional | | $145.30 | $177.00 | $235.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.68 / $190.33 / $190.33
| Professional | | $164.68 | $190.33 | $190.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.00 / $190.00 / $301.00
| Professional | | $159.00 | $190.00 | $301.00 |