- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.11 / $1,862.09 / $1,862.09
| Facility | | $33.11 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $45.71 / $2,691.53
| Professional | | $30.20 | $45.71 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,398.83 / $3,311.31
| Professional | | $1,445.44 | $2,398.83 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Facility | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $2,089.30 / $3,467.37
| Professional | | $575.44 | $2,089.30 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $70.79 / $109.65
| Professional | | $52.48 | $70.79 | $109.65 |