- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $2,398.83 / $6,606.93
| Facility | | $501.19 | $2,398.83 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $109.65 / $190.55
| Professional | | $93.33 | $109.65 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $154.88 / $181.97
| Professional | | $112.20 | $154.88 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.15 / $158.49 / $1,862.09
| Facility | | $107.15 | $158.49 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $134.90 / $1,000.00
| Professional | | $104.71 | $134.90 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $707.95 / $1,659.59
| Facility | | $138.04 | $707.95 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $117.49 / $165.96
| Professional | | $93.33 | $117.49 | $165.96 |