- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $198.70 / $244.41 / $244.41
| Facility | | $198.70 | $244.41 | $244.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.43 / $198.70 / $244.41
| Professional | | $177.43 | $198.70 | $244.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.88 / $213.84 / $300.00
| Professional | | $130.88 | $213.84 | $300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.28 / $191.28 / $191.28
| Professional | | $191.28 | $191.28 | $191.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.46 / $244.41 / $508.37
| Facility | | $165.46 | $244.41 | $508.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.00 / $1,274.00 / $1,274.00
| Professional | | $1,274.00 | $1,274.00 | $1,274.00 |