- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.83 / $512.86 / $1,000.00
| Facility | | $131.83 | $512.86 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $144.54 / $204.17
| Professional | | $120.23 | $144.54 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.50 / $141.25 / $758.58
| Facility | | $95.50 | $141.25 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $269.15 / $891.25
| Professional | | $223.87 | $269.15 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $112.20 / $158.49
| Professional | | $112.20 | $112.20 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $151.36 / $165.96
| Professional | | $112.20 | $151.36 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $77.62 / $165.96 / $186.21
| Facility | | $77.62 | $165.96 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $77.62 / $275.42
| Professional | | $64.57 | $77.62 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $112.20 / $112.20
| Professional | | $50.12 | $112.20 | $112.20 |