- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.85 / $743.28 / $3,140.00
| Facility | | $106.85 | $743.28 | $3,140.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.40 / $147.28 / $230.61
| Professional | | $84.40 | $147.28 | $230.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.87 / $216.00 / $271.31
| Professional | | $85.87 | $216.00 | $271.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $235.24 / $756.09 / $2,084.81
| Facility | | $235.24 | $756.09 | $2,084.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.99 / $194.81 / $484.15
| Professional | | $143.99 | $194.81 | $484.15 |