- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,623.41 / $10,471.29
| Facility | | $1,949.84 | $5,623.41 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.90 / $57.54 / $208.93
| Professional | | $38.90 | $57.54 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $107.15 / $107.15
| Professional | | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.48 / $2,187.76 / $8,709.64
| Facility | | $52.48 | $2,187.76 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $58.88 / $831.76
| Professional | | $30.20 | $58.88 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,715.35 / $8,912.51
| Facility | | $1,819.70 | $3,715.35 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $57.54 / $100.00
| Professional | | $30.20 | $57.54 | $100.00 |