- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.91 / $1,070.00 / $2,812.00
| Facility | | $122.91 | $1,070.00 | $2,812.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.72 / $126.45 / $214.48
| Professional | | $102.72 | $126.45 | $214.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.17 / $159.08 / $307.13
| Professional | | $108.17 | $159.08 | $307.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.62 / $153.85 / $271.33
| Professional | | $104.62 | $153.85 | $271.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.00 / $328.00 / $858.00
| Facility | | $130.00 | $328.00 | $858.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.70 / $269.58 / $465.34
| Professional | | $219.70 | $269.58 | $465.34 |