- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.33 / $1,000.00 / $2,812.00
| Facility | | $109.33 | $1,000.00 | $2,812.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.86 / $109.33 / $136.13
| Professional | | $57.86 | $109.33 | $136.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.38 / $126.23 / $158.55
| Professional | | $95.38 | $126.23 | $158.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.78 / $121.05 / $174.35
| Professional | | $74.78 | $121.05 | $174.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.00 / $345.00 / $768.00
| Facility | | $130.00 | $345.00 | $768.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.83 / $127.40 / $223.95
| Professional | | $88.83 | $127.40 | $223.95 |