- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $342.00 / $3,276.00 / $11,481.00
| Facility | | $342.00 | $3,276.00 | $11,481.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.24 / $250.48 / $272.86
| Professional | | $131.24 | $250.48 | $272.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.05 / $119.26 / $135.94
| Professional | | $91.05 | $119.26 | $135.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $50.00
| Professional | | $40.00 | $40.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.84 / $191.45 / $355.36
| Professional | | $167.84 | $191.45 | $355.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.40 / $137.40 / $137.40
| Professional | | $137.40 | $137.40 | $137.40 |