- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $613.33 / $7,838.38 / $7,838.38
| Facility | | $613.33 | $7,838.38 | $7,838.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.44 / $613.33 / $638.02
| Professional | | $172.44 | $613.33 | $638.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $332.80 / $1,663.97
| Professional | | $60.00 | $332.80 | $1,663.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,085.00 / $4,262.00 / $17,636.00
| Facility | | $3,085.00 | $4,262.00 | $17,636.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $543.21 / $872.10 / $1,531.36
| Professional | | $543.21 | $872.10 | $1,531.36 |