- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.15 / $685.98 / $6,907.00
| Facility | | $100.15 | $685.98 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.06 / $208.24 / $266.92
| Professional | | $93.06 | $208.24 | $266.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.50 / $166.94 / $320.08
| Professional | | $106.50 | $166.94 | $320.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,752.85 / $8,679.29 / $27,706.70
| Facility | | $1,752.85 | $8,679.29 | $27,706.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.95 / $363.34 / $490.82
| Professional | | $211.95 | $363.34 | $490.82 |