- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.31 / $108.31 / $203.76
| Facility | | $108.31 | $108.31 | $203.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.76 / $242.58 / $1,317.10
| Professional | | $203.76 | $242.58 | $1,317.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,481.10 / $6,651.58 / $8,948.50
| Facility | | $5,481.10 | $6,651.58 | $8,948.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.80 / $165.48 / $195.27
| Professional | | $120.80 | $165.48 | $195.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,293.33 / $9,192.37 / $9,540.74
| Facility | | $4,293.33 | $9,192.37 | $9,540.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.50 / $174.67 / $492.13
| Professional | | $134.50 | $174.67 | $492.13 |