- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $6,760.83 / $8,709.64
| Facility | | $1,288.25 | $6,760.83 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $1,659.59
| Professional | | $64.57 | $64.57 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $75.86 / $100.00
| Professional | | $75.86 | $75.86 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $97.72 / $1,819.70
| Facility | | $64.57 | $97.72 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $11,220.18 / $22,908.68
| Facility | | $1,905.46 | $11,220.18 | $22,908.68 |