- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.63 / $2,562.00 / $4,050.00
| Facility | | $107.63 | $2,562.00 | $4,050.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.66 / $102.71 / $117.09
| Professional | | $100.66 | $102.71 | $117.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,091.38 / $3,631.76 / $5,254.85
| Facility | | $2,091.38 | $3,631.76 | $5,254.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $746.00 / $2,415.00 / $6,585.00
| Facility | | $746.00 | $2,415.00 | $6,585.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.33 / $145.54 / $236.21
| Professional | | $98.33 | $145.54 | $236.21 |