- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.63 / $195.63 / $227.31
| Facility | | $195.63 | $195.63 | $227.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.55 / $154.01 / $195.63
| Professional | | $135.55 | $154.01 | $195.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.16 / $235.80 / $262.00
| Professional | | $178.16 | $235.80 | $262.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.06 / $141.06 / $141.06
| Professional | | $141.06 | $141.06 | $141.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.55 / $198.87 / $243.57
| Professional | | $163.55 | $198.87 | $243.57 |