- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.63 / $142.63 / $192.55
| Facility | | $142.63 | $142.63 | $192.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.62 / $142.63 / $200.00
| Professional | | $142.62 | $142.63 | $200.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.63 / $142.63 / $142.63
| Facility | | $142.63 | $142.63 | $142.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.63 / $142.63 / $142.63
| Professional | | $142.63 | $142.63 | $142.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.63 / $142.63 / $142.63
| Facility | | $142.63 | $142.63 | $142.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.02 / $121.59 / $264.11
| Professional | | $65.02 | $121.59 | $264.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.10 / $85.58 / $213.95
| Professional | | $61.10 | $85.58 | $213.95 |