- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $148.01 / $148.01 / $148.01
| Facility | | $148.01 | $148.01 | $148.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.01 / $166.68 / $216.00
| Professional | | $148.01 | $166.68 | $216.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.23 / $245.23 / $245.23
| Professional | | $245.23 | $245.23 | $245.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.63 / $204.49 / $1,464.05
| Facility | | $162.63 | $204.49 | $1,464.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.18 / $247.80 / $1,308.32
| Professional | | $196.18 | $247.80 | $1,308.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.18 / $220.54 / $399.58
| Professional | | $196.18 | $220.54 | $399.58 |