- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.87 / $482.14 / $2,757.84
| Facility | | $109.87 | $482.14 | $2,757.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.87 / $136.06 / $176.21
| Professional | | $109.87 | $136.06 | $176.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $471.29 / $1,062.40 / $2,209.33
| Facility | | $471.29 | $1,062.40 | $2,209.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.25 / $631.60 / $878.46
| Professional | | $506.25 | $631.60 | $878.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.70 / $482.14 / $8,702.00
| Facility | | $287.70 | $482.14 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.07 / $124.39 / $310.97
| Professional | | $87.07 | $124.39 | $310.97 |