- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.40 / $209.86 / $3,949.00
| Facility | | $134.40 | $209.86 | $3,949.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.40 / $204.61 / $209.86
| Professional | | $134.40 | $204.61 | $209.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.28 / $211.91 / $301.25
| Professional | | $141.28 | $211.91 | $301.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.84 / $215.84 / $215.84
| Professional | | $215.84 | $215.84 | $215.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.10 / $229.74 / $348.00
| Professional | | $191.10 | $229.74 | $348.00 |