- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.98 / $3,630.78 / $7,943.28
| Facility | | $194.98 | $3,630.78 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $114.82 / $208.93
| Professional | | $93.33 | $114.82 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $177.83 / $194.98
| Professional | | $177.83 | $177.83 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $331.13
| Facility | | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $154.88 / $234.42
| Professional | | $114.82 | $154.88 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $165.96 / $2,818.38
| Facility | | $102.33 | $165.96 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $154.88 / $1,000.00
| Professional | | $120.23 | $154.88 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $537.03 / $1,905.46
| Facility | | $190.55 | $537.03 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $138.04 / $181.97
| Professional | | $114.82 | $138.04 | $181.97 |