- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.82 / $174.62 / $1,400.00
| Facility | | $142.82 | $174.62 | $1,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.82 / $160.49 / $197.57
| Professional | | $142.82 | $160.49 | $197.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.32 / $240.32 / $240.32
| Facility | | $240.32 | $240.32 | $240.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.66 / $228.23 / $659.52
| Professional | | $141.66 | $228.23 | $659.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.49 / $216.67 / $435.35
| Professional | | $138.49 | $216.67 | $435.35 |