- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.27 / $1,083.00 / $3,109.00
| Facility | | $146.27 | $1,083.00 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.62 / $146.27 / $234.03
| Professional | | $103.62 | $146.27 | $234.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,383.01 / $1,383.01 / $1,659.61
| Facility | | $1,383.01 | $1,383.01 | $1,659.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.27 / $151.25 / $168.05
| Professional | | $114.27 | $151.25 | $168.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $590.00 / $1,263.00 / $2,558.00
| Facility | | $590.00 | $1,263.00 | $2,558.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.71 / $149.88 / $235.22
| Professional | | $105.71 | $149.88 | $235.22 |