- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.21 / $2,137.96 / $7,762.47
| Facility | | $186.21 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $186.21 / $213.80
| Professional | | $112.20 | $186.21 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $2,818.38 / $7,079.46
| Professional | | $234.42 | $2,818.38 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $100.00 / $562.34
| Professional | | $95.50 | $100.00 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $7,943.28 / $26,915.35
| Facility | | $1,230.27 | $7,943.28 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $354.81 / $812.83
| Professional | | $223.87 | $354.81 | $812.83 |