- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $323.59 / $1,023.29
| Facility | | $213.80 | $323.59 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $104.71 / $107.15
| Professional | | $100.00 | $104.71 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $331.13
| Facility | | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $107.15 / $107.15
| Professional | | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.15 / $107.15 / $107.15
| Facility | | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $107.15 / $194.98
| Professional | | $107.15 | $107.15 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $107.15 / $128.82
| Professional | | $107.15 | $107.15 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $323.59 / $977.24
| Facility | | $213.80 | $323.59 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $107.15 / $123.03
| Professional | | $100.00 | $107.15 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $107.15 / $162.18
| Professional | | $107.15 | $107.15 | $162.18 |