- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $478.63 / $3,981.07
| Facility | | $478.63 | $478.63 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.13 / $45.71 / $100.00
| Professional | | $14.13 | $45.71 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.02 / $28.18 / $74.13
| Professional | | $12.02 | $28.18 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.60 / $42.66 / $131.83
| Professional | | $16.60 | $42.66 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.87 / $1,412.54 / $6,456.54
| Facility | | $416.87 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.60 / $38.02 / $97.72
| Professional | | $16.60 | $38.02 | $97.72 |