- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $340.88 / $3,496.65 / $4,601.00
| Facility | | $340.88 | $3,496.65 | $4,601.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.86 / $206.50 / $340.88
| Professional | | $140.86 | $206.50 | $340.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.51 / $173.84 / $3,307.00
| Professional | | $153.51 | $173.84 | $3,307.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.76 / $327.52 / $484.78
| Professional | | $138.76 | $327.52 | $484.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.32 / $312.81 / $312.81
| Professional | | $150.32 | $312.81 | $312.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,832.00 / $2,343.00 / $26,408.00
| Facility | | $1,832.00 | $2,343.00 | $26,408.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.97 / $288.86 / $481.39
| Professional | | $135.97 | $288.86 | $481.39 |