- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $102.33 / $128.82
| Facility | | $102.33 | $102.33 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.02 / $93.33 / $125.89
| Professional | | $3.02 | $93.33 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,162.28 / $6,165.95
| Facility | | $2,398.83 | $3,162.28 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $147.91 / $181.97
| Professional | | $147.91 | $147.91 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.02 / $3.02 / $100.00
| Facility | | $3.02 | $3.02 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $239.88 / $263.03
| Professional | | $141.25 | $239.88 | $263.03 |