- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.81 / $927.00 / $2,250.00
| Facility | | $141.81 | $927.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.16 / $141.81 / $174.32
| Professional | | $101.16 | $141.81 | $174.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.08 / $127.50 / $150.44
| Professional | | $93.08 | $127.50 | $150.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $241.00 / $850.00 / $1,349.00
| Facility | | $241.00 | $850.00 | $1,349.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.35 / $157.03 / $395.56
| Professional | | $118.35 | $157.03 | $395.56 |