- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.61 / $1,324.16 / $2,500.00
| Facility | | $109.61 | $1,324.16 | $2,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.92 / $132.84 / $177.00
| Professional | | $93.92 | $132.84 | $177.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.64 / $280.73 / $369.76
| Professional | | $217.64 | $280.73 | $369.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.91 / $310.41 / $501.07
| Professional | | $193.91 | $310.41 | $501.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.61 / $160.50 / $328.83
| Facility | | $109.61 | $160.50 | $328.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.52 / $280.95 / $1,194.16
| Professional | | $161.52 | $280.95 | $1,194.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.52 / $265.35 / $346.41
| Professional | | $161.52 | $265.35 | $346.41 |