- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $1,698.24 / $1,778.28
| Facility | | $30.20 | $1,698.24 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $57.54 / $1,995.26
| Professional | | $30.20 | $57.54 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.72 / $5.50 / $7.94
| Professional | | $3.72 | $5.50 | $7.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,071.52 / $1,513.56
| Professional | | $691.83 | $1,071.52 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,122.02 / $1,202.26
| Professional | | $676.08 | $1,122.02 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $67.61 / $100.00
| Professional | | $45.71 | $67.61 | $100.00 |