- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $309.03
| Facility | | $100.00 | $100.00 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $138.04 / $363.08
| Professional | | $100.00 | $138.04 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $3,630.78 / $6,606.93
| Facility | | $239.88 | $3,630.78 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $190.55 / $562.34
| Professional | | $107.15 | $190.55 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $1,445.44 / $2,691.53
| Facility | | $416.87 | $1,445.44 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $177.83 / $457.09
| Professional | | $102.33 | $177.83 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $70.79 / $177.83
| Professional | | $32.36 | $70.79 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $81.28 / $1,288.25 / $3,630.78
| Facility | | $81.28 | $1,288.25 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $181.97 / $436.52
| Professional | | $128.82 | $181.97 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $107.15 / $147.91
| Professional | | $107.15 | $107.15 | $147.91 |