- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,623.41
| Facility | | $5,370.32 | $5,370.32 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $141.25
| Professional | | $104.71 | $104.71 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $120.23 / $331.13
| Facility | | $100.00 | $120.23 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $107.15
| Professional | | $104.71 | $104.71 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $229.09
| Facility | | $104.71 | $104.71 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Professional | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $72.44 / $87.10
| Professional | | $72.44 | $72.44 | $87.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,623.41
| Facility | | $5,370.32 | $5,370.32 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $107.15 / $181.97
| Professional | | $104.71 | $107.15 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $165.96
| Professional | | $104.71 | $104.71 | $165.96 |