- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $85.11 / $281.84
| Professional | | $66.07 | $85.11 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $1,737.80 / $3,090.30
| Facility | | $616.60 | $1,737.80 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.70 / $63.10 / $181.97
| Professional | | $53.70 | $63.10 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $3,311.31 / $5,754.40
| Facility | | $309.03 | $3,311.31 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $147.91 / $190.55
| Professional | | $87.10 | $147.91 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.74 / $69.18 / $158.49
| Professional | | $40.74 | $69.18 | $158.49 |