- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $148.32 / $148.32 / $182.84
| Facility | | $148.32 | $148.32 | $182.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.47 / $162.88 / $201.00
| Professional | | $137.47 | $162.88 | $201.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.90 / $164.05 / $230.30
| Professional | | $158.90 | $164.05 | $230.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.06 / $141.06 / $141.06
| Professional | | $141.06 | $141.06 | $141.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.13 / $177.25 / $397.94
| Facility | | $136.13 | $177.25 | $397.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.94 / $219.82 / $1,105.55
| Professional | | $152.94 | $219.82 | $1,105.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.94 / $203.32 / $291.88
| Professional | | $152.94 | $203.32 | $291.88 |