- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.54 / $1,000.00 / $5,764.32
| Facility | | $125.54 | $1,000.00 | $5,764.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.34 / $124.88 / $148.29
| Professional | | $112.34 | $124.88 | $148.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.54 / $142.54 / $151.44
| Professional | | $142.54 | $142.54 | $151.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.78 / $195.78 / $195.78
| Facility | | $195.78 | $195.78 | $195.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.41 / $166.41 / $166.41
| Professional | | $166.41 | $166.41 | $166.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.90 / $167.90 / $167.90
| Facility | | $167.90 | $167.90 | $167.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.78 / $167.90 / $237.48
| Professional | | $167.78 | $167.90 | $237.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,407.10 / $1,407.10 / $1,407.10
| Facility | | $1,407.10 | $1,407.10 | $1,407.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.34 / $128.86 / $178.39
| Professional | | $98.34 | $128.86 | $178.39 |