- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.40 / $1,374.00 / $6,907.00
| Facility | | $239.40 | $1,374.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.19 / $40.11 / $59.78
| Professional | | $27.19 | $40.11 | $59.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.38 / $47.15 / $59.78
| Professional | | $26.38 | $47.15 | $59.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $69.40 / $73.20 / $366.95
| Facility | | $69.40 | $73.20 | $366.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.40 / $51.79 / $122.78
| Professional | | $38.40 | $51.79 | $122.78 |