- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.62 / $101.62 / $157.56
| Facility | | $101.62 | $101.62 | $157.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.23 / $140.29 / $164.18
| Professional | | $101.23 | $140.29 | $164.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.46 / $267.20 / $412.81
| Professional | | $206.46 | $267.20 | $412.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.31 / $266.39 / $529.45
| Professional | | $150.31 | $266.39 | $529.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.62 / $172.39 / $287.66
| Facility | | $101.62 | $172.39 | $287.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.76 / $300.45 / $900.00
| Professional | | $162.76 | $300.45 | $900.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.76 / $288.08 / $388.61
| Professional | | $162.76 | $288.08 | $388.61 |