- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $163.26 / $163.26 / $5,916.00
| Facility | | $163.26 | $163.26 | $5,916.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $163.26 / $167.94
| Professional | | $151.16 | $163.26 | $167.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.61 / $142.61 / $151.16
| Facility | | $142.61 | $142.61 | $151.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $151.16
| Professional | | $151.16 | $151.16 | $151.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.86 / $170.48 / $400.80
| Facility | | $109.86 | $170.48 | $400.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.47 / $150.33 / $222.08
| Professional | | $144.47 | $150.33 | $222.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $166.70
| Professional | | $151.16 | $151.16 | $166.70 |