- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.36 / $231.05 / $1,600.00
| Facility | | $116.36 | $231.05 | $1,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.36 / $173.12 / $279.89
| Professional | | $116.36 | $173.12 | $279.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.63 / $134.06 / $146.07
| Facility | | $116.63 | $134.06 | $146.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.84 / $129.84 / $129.84
| Professional | | $129.84 | $129.84 | $129.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $187.02 / $187.02 / $187.02
| Facility | | $187.02 | $187.02 | $187.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.63 / $252.62 / $511.40
| Professional | | $143.63 | $252.62 | $511.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.85 / $220.98 / $336.85
| Professional | | $157.85 | $220.98 | $336.85 |