- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $732.00 / $732.00 / $732.00
| Facility | | $732.00 | $732.00 | $732.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.60 / $242.10 / $294.49
| Professional | | $206.60 | $242.10 | $294.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.20 / $106.20 / $106.20
| Professional | | $106.20 | $106.20 | $106.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.58 / $207.49 / $344.40
| Professional | | $138.58 | $207.49 | $344.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.33 / $32.20 / $2,500.00
| Professional | | $31.33 | $32.20 | $2,500.00 |