- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $141.25 / $1,000.00
| Professional | | $114.82 | $141.25 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.78 / $257.04 / $851.14
| Facility | | $218.78 | $257.04 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $218.78 / $218.78
| Professional | | $218.78 | $218.78 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $223.87 / $467.74
| Facility | | $151.36 | $223.87 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $223.87 / $467.74
| Professional | | $151.36 | $223.87 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $257.04 / $851.14
| Facility | | $134.90 | $257.04 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $134.90 / $239.88
| Professional | | $134.90 | $134.90 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.10 / $63.10 / $151.36
| Professional | | $63.10 | $63.10 | $151.36 |