- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,548.82 / $3,981.07
| Facility | | $1,513.56 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.70 / $39.81 / $100.00
| Professional | | $25.70 | $39.81 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.70 / $34.67 / $61.66
| Professional | | $25.70 | $34.67 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.92 / $57.54 / $302.00
| Professional | | $26.92 | $57.54 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $1,412.54 / $6,456.54
| Facility | | $436.52 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.31 / $46.77 / $83.18
| Professional | | $36.31 | $46.77 | $83.18 |