- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,007.57 / $2,007.57 / $2,007.57
| Facility | | $2,007.57 | $2,007.57 | $2,007.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.68 / $861.86 / $1,045.60
| Professional | | $6.68 | $861.86 | $1,045.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.73 / $167.73 / $184.06
| Professional | | $167.73 | $167.73 | $184.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.67 / $861.86 / $1,232.46
| Facility | | $39.67 | $861.86 | $1,232.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.62 / $106.62 / $106.62
| Professional | | $106.62 | $106.62 | $106.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $3,900.00
| Professional | | $30.00 | $30.00 | $3,900.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.13 / $63.68 / $825.59
| Professional | | $54.13 | $63.68 | $825.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.36 / $1,105.20 / $1,893.11
| Professional | | $1,042.36 | $1,105.20 | $1,893.11 |