- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.38 / $1,040.00 / $1,998.78
| Facility | | $104.38 | $1,040.00 | $1,998.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.31 / $112.33 / $252.88
| Professional | | $102.31 | $112.33 | $252.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.00 / $491.00 / $491.00
| Professional | | $491.00 | $491.00 | $491.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.23 / $194.13 / $275.16
| Professional | | $122.23 | $194.13 | $275.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.00 / $513.00 / $1,739.00
| Facility | | $225.00 | $513.00 | $1,739.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.02 / $129.60 / $285.12
| Professional | | $102.02 | $129.60 | $285.12 |