- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $294.02 / $1,543.03 / $3,955.04
| Facility | | $294.02 | $1,543.03 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.68 / $76.23 / $97.04
| Professional | | $43.68 | $76.23 | $97.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.43 / $84.62 / $163.25
| Professional | | $47.43 | $84.62 | $163.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.14 / $110.76 / $226.52
| Professional | | $56.14 | $110.76 | $226.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.45 / $117.24 / $199.19
| Professional | | $77.45 | $117.24 | $199.19 |