- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.72 / $1,819.70 / $2,818.38
| Facility | | $97.72 | $1,819.70 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.66 / $97.72 / $112.20
| Professional | | $61.66 | $97.72 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,467.37
| Facility | | $2,884.03 | $2,884.03 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $114.82 / $114.82
| Professional | | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $2,691.53 / $6,165.95
| Facility | | $812.83 | $2,691.53 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $138.04 / $275.42
| Professional | | $102.33 | $138.04 | $275.42 |