- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.26 / $2,041.74 / $5,888.44
| Facility | | $60.26 | $2,041.74 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $263.03 / $645.65
| Professional | | $100.00 | $263.03 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $79.43 / $79.43
| Professional | | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $114.82 / $389.05
| Professional | | $114.82 | $114.82 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $776.25 / $1,949.84
| Facility | | $363.08 | $776.25 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $39.81 / $60.26
| Professional | | $34.67 | $39.81 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $6,025.60
| Professional | | $3,311.31 | $3,311.31 | $6,025.60 |