- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $117.49 / $3,311.31
| Facility | | $100.00 | $117.49 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $85.11 / $190.55
| Professional | | $72.44 | $85.11 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,905.46
| Facility | | $1,380.38 | $1,380.38 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $83.18 / $109.65
| Professional | | $83.18 | $83.18 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,445.44 / $4,365.16
| Facility | | $588.84 | $1,445.44 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.13 / $91.20 / $173.78
| Professional | | $74.13 | $91.20 | $173.78 |