- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.23 / $912.01 / $7,943.28
| Facility | | $120.23 | $912.01 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $190.55 / $398.11
| Professional | | $102.33 | $190.55 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $158.49 / $199.53
| Professional | | $102.33 | $158.49 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,122.02 / $6,918.31
| Facility | | $1,096.48 | $1,122.02 | $6,918.31 |
- 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
- $97.72 / $141.25 / $275.42
| Professional | | $97.72 | $141.25 | $275.42 |