- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $85.11 / $120.23
| Professional | | $60.26 | $85.11 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $58.88 / $131.83
| Professional | | $45.71 | $58.88 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $1,096.48
| Professional | | $794.33 | $794.33 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $204.17 / $263.03
| Professional | | $131.83 | $204.17 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $134.90 / $1,445.44
| Professional | | $125.89 | $134.90 | $1,445.44 |