- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $2,344.23 / $7,762.47
| Facility | | $741.31 | $2,344.23 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $199.53 / $645.65
| Professional | | $128.82 | $199.53 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,818.38 / $3,388.44
| Facility | | $2,089.30 | $2,818.38 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $331.13 / $446.68
| Professional | | $213.80 | $331.13 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $281.84 / $309.03
| Professional | | $275.42 | $281.84 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $5,128.61 / $11,481.54
| Facility | | $1,445.44 | $5,128.61 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $281.84 / $446.68
| Professional | | $213.80 | $281.84 | $446.68 |