- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $504.45 / $1,435.12 / $3,706.14
| Facility | | $504.45 | $1,435.12 | $3,706.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.60 / $49.79 / $81.97
| Professional | | $33.60 | $49.79 | $81.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.61 / $53.08 / $102.52
| Professional | | $36.61 | $53.08 | $102.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.32 / $78.15 / $110.13
| Professional | | $49.32 | $78.15 | $110.13 |
- 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
- $48.19 / $79.23 / $119.76
| Professional | | $48.19 | $79.23 | $119.76 |