- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.31 / $159.31 / $465.27
| Facility | | $159.31 | $159.31 | $465.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.85 / $159.31 / $425.04
| Professional | | $22.85 | $159.31 | $425.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.22 / $21.74 / $323.14
| Professional | | $12.22 | $21.74 | $323.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.35 / $84.44 / $971.06
| Professional | | $25.35 | $84.44 | $971.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.58 / $358.50 / $1,038.43
| Professional | | $26.58 | $358.50 | $1,038.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.01 / $320.81 / $405.43
| Professional | | $83.01 | $320.81 | $405.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.22 / $301.38 / $3,000.00
| Professional | | $19.22 | $301.38 | $3,000.00 |