- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.96 / $256.48 / $1,600.00
| Facility | | $130.96 | $256.48 | $1,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.96 / $207.28 / $308.63
| Professional | | $130.96 | $207.28 | $308.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.30 / $157.22 / $171.30
| Facility | | $141.30 | $157.22 | $171.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.27 / $152.27 / $152.27
| Professional | | $152.27 | $152.27 | $152.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $226.58 / $226.58 / $226.58
| Facility | | $226.58 | $226.58 | $226.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.27 / $313.58 / $629.17
| Professional | | $152.27 | $313.58 | $629.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.80 / $293.76 / $499.86
| Professional | | $195.80 | $293.76 | $499.86 |