- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $100.00 / $630.96
| Professional | | $47.86 | $100.00 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $16,218.10 / $16,218.10
| Facility | | $213.80 | $16,218.10 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $691.83 / $691.83
| Professional | | $630.96 | $691.83 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,630.27 / $2,951.21
| Facility | | $1,737.80 | $2,630.27 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.88 / $85.11 / $131.83
| Professional | | $21.88 | $85.11 | $131.83 |