- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.75 / $140.84 / $1,400.00
| Facility | | $105.75 | $140.84 | $1,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.06 / $136.11 / $185.49
| Professional | | $101.06 | $136.11 | $185.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.23 / $115.47 / $137.59
| Facility | | $105.23 | $115.47 | $137.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.26 / $122.30 / $148.06
| Professional | | $80.26 | $122.30 | $148.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $185.16 / $185.16 / $185.16
| Facility | | $185.16 | $185.16 | $185.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.80 / $162.29 / $393.39
| Professional | | $110.80 | $162.29 | $393.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.83 / $153.77 / $236.50
| Professional | | $111.83 | $153.77 | $236.50 |