- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $123.03 / $537.03
| Professional | | $102.33 | $123.03 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $831.76 / $1,000.00
| Facility | | $616.60 | $831.76 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $97.72 / $263.03
| Professional | | $83.18 | $97.72 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $954.99 / $1,698.24
| Facility | | $426.58 | $954.99 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $239.88 / $281.84
| Professional | | $138.04 | $239.88 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $831.76
| Facility | | $831.76 | $831.76 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $158.49 / $218.78
| Professional | | $114.82 | $158.49 | $218.78 |