- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $3,715.35 / $3,981.07
| Facility | | $575.44 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.92 / $12.88 / $26.92
| Professional | | $6.92 | $12.88 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.75 / $10.47 / $16.60
| Professional | | $5.75 | $10.47 | $16.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.76 / $16.22 / $29.51
| Professional | | $7.76 | $16.22 | $29.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $1,412.54 / $6,456.54
| Facility | | $316.23 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.94 / $14.13 / $26.92
| Professional | | $7.94 | $14.13 | $26.92 |