- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.50 / $4,396.00 / $10,300.00
| Facility | | $105.50 | $4,396.00 | $10,300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.92 / $105.50 / $161.34
| Professional | | $60.92 | $105.50 | $161.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.88 / $132.26 / $196.08
| Professional | | $97.88 | $132.26 | $196.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.00 / $200.00 / $493.00
| Professional | | $200.00 | $200.00 | $493.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.00 / $1,427.00 / $1,998.00
| Facility | | $200.00 | $1,427.00 | $1,998.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.64 / $116.51 / $184.72
| Professional | | $87.64 | $116.51 | $184.72 |