- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.11 / $191.06 / $5,354.40
| Facility | | $97.11 | $191.06 | $5,354.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.95 / $143.97 / $200.61
| Professional | | $113.95 | $143.97 | $200.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,431.23 / $2,950.43 / $3,969.27
| Facility | | $2,431.23 | $2,950.43 | $3,969.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.04 / $153.47 / $181.11
| Professional | | $112.04 | $153.47 | $181.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $292.17 / $3,138.00 / $4,884.05
| Facility | | $292.17 | $3,138.00 | $4,884.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.03 / $204.29 / $518.58
| Professional | | $117.03 | $204.29 | $518.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,575.48 / $5,542.56 / $5,723.32
| Facility | | $2,575.48 | $5,542.56 | $5,723.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.45 / $160.60 / $490.68
| Professional | | $120.45 | $160.60 | $490.68 |