- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.65 / $32.86 / $1,061.65
| Facility | | $24.65 | $32.86 | $1,061.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.26 / $804.28 / $1,136.65
| Professional | | $26.26 | $804.28 | $1,136.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.92 / $39.90 / $1,542.36
| Professional | | $33.92 | $39.90 | $1,542.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.57 / $1,077.57 / $1,077.57
| Professional | | $1,077.57 | $1,077.57 | $1,077.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.53 / $1,036.02 / $1,361.67
| Facility | | $33.53 | $1,036.02 | $1,361.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.74 / $1,302.26 / $7,170.93
| Professional | | $222.74 | $1,302.26 | $7,170.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.78 / $1,294.46 / $1,814.97
| Professional | | $1,053.78 | $1,294.46 | $1,814.97 |