- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $109.65 / $1,000.00
| Facility | | $104.71 | $109.65 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $109.65 / $112.20
| Professional | | $104.71 | $109.65 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $69.18 / $87.10 / $218.78
| Facility | | $69.18 | $87.10 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.18 / $69.18 / $91.20
| Professional | | $28.18 | $69.18 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.20 / $112.20 / $112.20
| Facility | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $112.20 / $112.20
| Professional | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $131.83 / $416.87
| Professional | | $75.86 | $131.83 | $416.87 |