- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.16 / $245.40 / $1,059.33
| Facility | | $98.16 | $245.40 | $1,059.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.16 / $144.46 / $157.41
| Professional | | $98.16 | $144.46 | $157.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.03 / $408.50 / $848.65
| Facility | | $181.03 | $408.50 | $848.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.46 / $242.61 / $337.43
| Professional | | $194.46 | $242.61 | $337.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,702.00 / $8,702.00 / $8,702.00
| Facility | | $8,702.00 | $8,702.00 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.78 / $111.12 / $200.02
| Professional | | $77.78 | $111.12 | $200.02 |