- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.44 / $130.44 / $778.24
| Facility | | $130.44 | $130.44 | $778.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.44 / $131.21 / $356.00
| Professional | | $130.44 | $131.21 | $356.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.16 / $183.30 / $186.14
| Facility | | $141.16 | $183.30 | $186.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.45 / $112.45 / $112.45
| Professional | | $112.45 | $112.45 | $112.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $197.61 / $249.69 / $353.74
| Facility | | $197.61 | $249.69 | $353.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.83 / $112.45 / $112.45
| Professional | | $106.83 | $112.45 | $112.45 |