- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.07 / $126.07 / $151.28
| Facility | | $126.07 | $126.07 | $151.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.07 / $126.07 / $126.07
| Professional | | $126.07 | $126.07 | $126.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.06 / $100.00 / $100.00
| Professional | | $93.06 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.65 / $58.65 / $58.65
| Professional | | $58.65 | $58.65 | $58.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.06 / $242.75 / $494.03
| Professional | | $160.06 | $242.75 | $494.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.06 / $160.06 / $160.06
| Professional | | $160.06 | $160.06 | $160.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.75 / $142.50 / $209.48
| Professional | | $118.75 | $142.50 | $209.48 |