- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.82 / $114.82 / $288.40
| Facility | | $114.82 | $114.82 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $100.00 / $199.53
| Professional | | $87.10 | $100.00 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $144.54 / $229.09
| Professional | | $104.71 | $144.54 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.33 / $141.25 / $239.88
| Facility | | $93.33 | $141.25 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $6,918.31 / $9,120.11
| Facility | | $2,454.71 | $6,918.31 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $123.03 / $208.93
| Professional | | $91.20 | $123.03 | $208.93 |