- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.70 / $207.39 / $5,967.58
| Facility | | $80.70 | $207.39 | $5,967.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.31 / $124.20 / $127.30
| Professional | | $80.31 | $124.20 | $127.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.28 / $134.47 / $194.79
| Professional | | $91.28 | $134.47 | $194.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,132.00 / $6,132.00 / $6,132.00
| Facility | | $6,132.00 | $6,132.00 | $6,132.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.82 / $159.54 / $410.93
| Professional | | $119.82 | $159.54 | $410.93 |