- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $4,073.80 / $4,570.88
| Facility | | $144.54 | $4,073.80 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $234.42 / $389.05
| Professional | | $128.82 | $234.42 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $1,949.84 / $5,128.61
| Professional | | $120.23 | $1,949.84 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $229.09 / $489.78
| Professional | | $123.03 | $229.09 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $245.47 / $501.19
| Professional | | $234.42 | $245.47 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $8,128.31 / $26,302.68
| Facility | | $1,023.29 | $8,128.31 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $234.42 / $478.63
| Professional | | $112.20 | $234.42 | $478.63 |