- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.96 / $2,089.30 / $7,943.28
| Facility | | $165.96 | $2,089.30 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $177.83 / $446.68
| Professional | | $100.00 | $177.83 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,715.35 / $9,549.93
| Facility | | $1,513.56 | $3,715.35 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $169.82 / $309.03
| Professional | | $104.71 | $169.82 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.11 / $257.04 / $1,122.02
| Facility | | $85.11 | $257.04 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $186.21 / $398.11
| Professional | | $114.82 | $186.21 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $1,096.48 / $3,467.37
| Facility | | $245.47 | $1,096.48 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $154.88 / $288.40
| Professional | | $100.00 | $154.88 | $288.40 |