- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $758.58 / $977.24
| Facility | | $616.60 | $758.58 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $562.34 / $977.24
| Professional | | $72.44 | $562.34 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.90 / $30.90 / $660.69
| Professional | | $30.90 | $30.90 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $645.65 / $1,000.00
| Facility | | $64.57 | $645.65 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $1,000.00 / $3,630.78
| Professional | | $151.36 | $1,000.00 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $245.47 / $1,023.29
| Facility | | $245.47 | $245.47 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,000.00 / $1,412.54
| Professional | | $812.83 | $1,000.00 | $1,412.54 |