- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $3,162.28 / $4,570.88
| Facility | | $109.65 | $3,162.28 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $89.13 / $199.53
| Professional | | $77.62 | $89.13 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $123.03 / $169.82
| Professional | | $93.33 | $123.03 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $162.18
| Professional | | $32.36 | $33.11 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $154.88 / $194.98
| Professional | | $100.00 | $154.88 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.18 / $144.54 / $204.17
| Professional | | $69.18 | $144.54 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $114.82 / $158.49
| Professional | | $95.50 | $114.82 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,128.61 / $13,803.84
| Facility | | $2,290.87 | $5,128.61 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.13 / $102.33 / $162.18
| Professional | | $74.13 | $102.33 | $162.18 |