- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $3,162.28 / $7,762.47
| Facility | | $134.90 | $3,162.28 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $128.82 / $223.87
| Professional | | $107.15 | $128.82 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $128.82 / $2,089.30
| Professional | | $102.33 | $128.82 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $138.04 / $389.05
| Professional | | $104.71 | $138.04 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $120.23 / $263.03
| Professional | | $114.82 | $120.23 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $10,000.00 / $29,512.09
| Facility | | $3,311.31 | $10,000.00 | $29,512.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $128.82 / $288.40
| Professional | | $95.50 | $128.82 | $288.40 |