- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $119.61 / $119.61 / $128.00
| Facility | | $119.61 | $119.61 | $128.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.70 / $119.61 / $119.61
| Professional | | $39.70 | $119.61 | $119.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.31 / $123.14 / $374.12
| Facility | | $107.31 | $123.14 | $374.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.67 / $140.72 / $140.72
| Professional | | $106.67 | $140.72 | $140.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.35 / $131.35 / $131.35
| Facility | | $131.35 | $131.35 | $131.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.35 / $131.35 / $131.35
| Professional | | $131.35 | $131.35 | $131.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.61 / $119.61 / $190.00
| Professional | | $119.61 | $119.61 | $190.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.28 / $132.53 / $140.74
| Professional | | $117.28 | $132.53 | $140.74 |