- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $5,370.32 / $9,549.93
| Facility | | $138.04 | $5,370.32 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $123.03 / $239.88
| Professional | | $87.10 | $123.03 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,089.30 / $3,548.13
| Facility | | $794.33 | $2,089.30 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $144.54 / $239.88
| Professional | | $100.00 | $144.54 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $138.04 / $275.42
| Professional | | $87.10 | $138.04 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $177.83 / $309.03
| Professional | | $100.00 | $177.83 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $1,513.56 / $2,511.89
| Facility | | $354.81 | $1,513.56 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $162.18 / $281.84
| Professional | | $104.71 | $162.18 | $281.84 |