- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.86 / $1,142.00 / $22,106.63
| Facility | | $47.86 | $1,142.00 | $22,106.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $47.86 / $1,456.81
| Professional | | $47.86 | $47.86 | $1,456.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,638.30 / $1,638.30 / $3,161.92
| Facility | | $1,638.30 | $1,638.30 | $3,161.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.64 / $1,638.30 / $2,326.38
| Professional | | $1,310.64 | $1,638.30 | $2,326.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.60 / $7.60 / $2,162.56
| Professional | | $7.60 | $7.60 | $2,162.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.00 / $2,252.00 / $4,426.00
| Facility | | $933.00 | $2,252.00 | $4,426.00 |