- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $601.16 / $2,211.19 / $3,616.69
| Facility | | $601.16 | $2,211.19 | $3,616.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.87 / $561.16 / $701.45
| Professional | | $420.87 | $561.16 | $701.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.31 / $362.20 / $6,124.00
| Facility | | $162.31 | $362.20 | $6,124.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.42 / $123.88 / $262.61
| Professional | | $104.42 | $123.88 | $262.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.97 / $120.62 / $202.26
| Professional | | $103.97 | $120.62 | $202.26 |