- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $217.65 / $4,370.00 / $10,692.00
| Facility | | $217.65 | $4,370.00 | $10,692.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.47 / $527.05 / $977.36
| Professional | | $166.47 | $527.05 | $977.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.79 / $547.44 / $2,067.23
| Professional | | $195.79 | $547.44 | $2,067.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $312.58 / $935.15 / $1,083.92
| Professional | | $312.58 | $935.15 | $1,083.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.38 / $663.82 / $1,260.63
| Professional | | $137.38 | $663.82 | $1,260.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,529.00 / $3,352.00 / $10,536.00
| Facility | | $1,529.00 | $3,352.00 | $10,536.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.08 / $871.39 / $2,260.56
| Professional | | $540.08 | $871.39 | $2,260.56 |