- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.93 / $3,090.30 / $11,481.54
| Facility | | $208.93 | $3,090.30 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $131.83 / $501.19
| Professional | | $107.15 | $131.83 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $4,677.35 / $13,182.57
| Facility | | $2,511.89 | $4,677.35 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $158.49 / $281.84
| Professional | | $114.82 | $158.49 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.97 / $354.81 / $1,000.00
| Facility | | $181.97 | $354.81 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $173.78 / $380.19
| Professional | | $114.82 | $173.78 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $1,202.26 / $3,715.35
| Facility | | $269.15 | $1,202.26 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $138.04 / $257.04
| Professional | | $97.72 | $138.04 | $257.04 |