- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.37 / $108.37 / $1,400.00
| Facility | | $108.37 | $108.37 | $1,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.90 / $108.37 / $141.30
| Professional | | $100.90 | $108.37 | $141.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.61 / $136.63 / $148.86
| Facility | | $122.61 | $136.63 | $148.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.32 / $132.32 / $132.32
| Professional | | $132.32 | $132.32 | $132.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.08 / $133.08 / $133.08
| Facility | | $133.08 | $133.08 | $133.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.93 / $184.44 / $886.89
| Professional | | $111.93 | $184.44 | $886.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.26 / $153.10 / $234.33
| Professional | | $101.26 | $153.10 | $234.33 |