- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $2,754.23 / $2,884.03
| Facility | | $30.20 | $2,754.23 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $57.54 / $2,754.23
| Professional | | $30.20 | $57.54 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.02 / $5.01 / $6.61
| Professional | | $3.02 | $5.01 | $6.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,819.70 / $2,511.89
| Professional | | $1,148.15 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,819.70 / $1,995.26
| Professional | | $1,096.48 | $1,819.70 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $67.61 / $100.00
| Professional | | $45.71 | $67.61 | $100.00 |