- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.52 / $152.52 / $155.36
| Facility | | $152.52 | $152.52 | $155.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.13 / $178.74 / $224.37
| Professional | | $125.13 | $178.74 | $224.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.00 / $284.00 / $284.00
| Professional | | $230.00 | $284.00 | $284.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.06 / $176.50 / $249.23
| Professional | | $141.06 | $176.50 | $249.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.71 / $334.10 / $509.26
| Professional | | $247.71 | $334.10 | $509.26 |