- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.67 / $2,089.30 / $2,290.87
| Facility | | $44.67 | $2,089.30 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $47.86 / $2,754.23
| Professional | | $32.36 | $47.86 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,202.26 / $1,995.26
| Professional | | $660.69 | $1,202.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,778.28 / $2,511.89
| Professional | | $1,258.93 | $1,778.28 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,778.28
| Professional | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.69 / $66.07 / $97.72
| Professional | | $41.69 | $66.07 | $97.72 |