- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.66 / $4,486.33 / $23,620.21
| Facility | | $204.66 | $4,486.33 | $23,620.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.74 / $2,673.50 / $2,673.50
| Professional | | $9.74 | $2,673.50 | $2,673.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.40 / $125.40 / $125.40
| Professional | | $125.40 | $125.40 | $125.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $50.00 / $50.00
| Professional | | $40.00 | $50.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.00 / $750.00 / $750.00
| Professional | | $750.00 | $750.00 | $750.00 |