- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,973.53 / $1,973.53 / $8,224.95
| Facility | | $1,973.53 | $1,973.53 | $8,224.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.36 / $1,483.00 / $2,529.09
| Professional | | $62.36 | $1,483.00 | $2,529.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.14 / $49.37 / $86.16
| Professional | | $37.14 | $49.37 | $86.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $29.53 / $1,140.77 / $1,711.16
| Facility | | $29.53 | $1,140.77 | $1,711.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,475.00 / $2,475.00 / $5,535.00
| Professional | | $2,475.00 | $2,475.00 | $5,535.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.20 / $53.12 / $112.46
| Professional | | $33.20 | $53.12 | $112.46 |