- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $3,236.80 / $3,955.04
| Facility | | $2,090.73 | $3,236.80 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.10 / $81.34 / $206.30
| Professional | | $42.10 | $81.34 | $206.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.84 / $89.60 / $147.26
| Professional | | $47.84 | $89.60 | $147.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.68 / $110.12 / $238.82
| Professional | | $66.68 | $110.12 | $238.82 |
- 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
- $85.70 / $155.57 / $225.98
| Professional | | $85.70 | $155.57 | $225.98 |