- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.08 / $176.35 / $1,400.00
| Facility | | $107.08 | $176.35 | $1,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.08 / $173.58 / $213.98
| Professional | | $107.08 | $173.58 | $213.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.03 / $123.02 / $146.46
| Facility | | $112.03 | $123.02 | $146.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.19 / $130.19 / $130.19
| Professional | | $130.19 | $130.19 | $130.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $197.27 / $197.27 / $197.27
| Facility | | $197.27 | $197.27 | $197.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.19 / $234.57 / $559.70
| Professional | | $130.19 | $234.57 | $559.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.69 / $214.17 / $329.48
| Professional | | $146.69 | $214.17 | $329.48 |