- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $210.22 / $210.22 / $2,165.00
| Facility | | $210.22 | $210.22 | $2,165.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.22 / $210.22 / $210.22
| Professional | | $210.22 | $210.22 | $210.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.36 / $249.51 / $264.04
| Facility | | $203.36 | $249.51 | $264.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.22 / $181.22 / $181.22
| Professional | | $181.22 | $181.22 | $181.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.68 / $358.71 / $514.98
| Facility | | $287.68 | $358.71 | $514.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.16 / $181.22 / $181.22
| Professional | | $172.16 | $181.22 | $181.22 |