- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $168.33 / $168.33 / $240.00
| Facility | | $168.33 | $168.33 | $240.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.33 / $202.01 / $249.69
| Professional | | $168.33 | $202.01 | $249.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.37 / $211.16 / $309.27
| Professional | | $158.37 | $211.16 | $309.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.14 / $212.14 / $212.14
| Facility | | $212.14 | $212.14 | $212.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.27 / $146.27 / $873.09
| Professional | | $146.27 | $146.27 | $873.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $236.56
| Professional | | $32.34 | $32.34 | $236.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.68 / $217.71 / $377.48
| Professional | | $154.68 | $217.71 | $377.48 |