- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $1,288.25 / $2,454.71
| Facility | | $134.90 | $1,288.25 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $117.49 / $181.97
| Professional | | $100.00 | $117.49 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $120.23 / $120.23
| Professional | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $562.34
| Facility | | $512.86 | $512.86 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $151.36 / $199.53
| Professional | | $107.15 | $151.36 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $758.58 / $2,570.40
| Facility | | $371.54 | $758.58 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $131.83 / $208.93
| Professional | | $100.00 | $131.83 | $208.93 |