- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.18 / $1,541.04 / $5,454.23
| Facility | | $103.18 | $1,541.04 | $5,454.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.15 / $122.56 / $162.77
| Professional | | $79.15 | $122.56 | $162.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.17 / $127.46 / $193.05
| Professional | | $97.17 | $127.46 | $193.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,940.15 / $2,223.40 / $3,500.73
| Facility | | $1,940.15 | $2,223.40 | $3,500.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.53 / $157.44 / $339.79
| Professional | | $132.53 | $157.44 | $339.79 |