- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.00 / $140.61 / $254.72
| Facility | | $116.00 | $140.61 | $254.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.06 / $170.21 / $254.72
| Professional | | $114.06 | $170.21 | $254.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.00 / $204.00 / $204.00
| Professional | | $204.00 | $204.00 | $204.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.77 / $170.56 / $264.11
| Professional | | $106.77 | $170.56 | $264.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.28 / $146.40 / $254.25
| Professional | | $106.28 | $146.40 | $254.25 |