- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $2,691.53 / $2,691.53
| Facility | | $56.23 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.02 / $56.23 / $2,691.53
| Professional | | $38.02 | $56.23 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,621.81 / $2,187.76
| Professional | | $1,258.93 | $1,621.81 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,445.44 / $1,698.24
| Professional | | $616.60 | $1,445.44 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,819.70 / $2,290.87
| Professional | | $1,513.56 | $1,819.70 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.02 / $50.12 / $79.43
| Professional | | $38.02 | $50.12 | $79.43 |