- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.32 / $132.32 / $142.90
| Facility | | $132.32 | $132.32 | $142.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.32 / $135.62 / $690.78
| Professional | | $132.32 | $135.62 | $690.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.46 / $131.82 / $191.00
| Professional | | $105.46 | $131.82 | $191.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.55 / $141.78 / $211.71
| Professional | | $109.55 | $141.78 | $211.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.14 / $135.28 / $200.00
| Professional | | $31.14 | $135.28 | $200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.98 / $122.98 / $184.47
| Professional | | $122.98 | $122.98 | $184.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.12 / $128.84 / $224.91
| Professional | | $105.12 | $128.84 | $224.91 |