- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $1,659.59 / $1,659.59
| Facility | | $56.23 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.02 / $56.23 / $1,659.59
| Professional | | $38.02 | $56.23 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $977.24 / $1,318.26
| Professional | | $758.58 | $977.24 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $891.25 / $1,096.48
| Professional | | $380.19 | $891.25 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,122.02 / $1,412.54
| Professional | | $933.25 | $1,122.02 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.02 / $50.12 / $79.43
| Professional | | $38.02 | $50.12 | $79.43 |