- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $84.64 / $353.42 / $8,796.00
| Facility | | $84.64 | $353.42 | $8,796.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.59 / $126.56 / $137.52
| Professional | | $72.59 | $126.56 | $137.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.67 / $126.78 / $204.35
| Professional | | $97.67 | $126.78 | $204.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,766.11 / $8,766.11 / $8,766.11
| Facility | | $8,766.11 | $8,766.11 | $8,766.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.86 / $173.01 / $346.02
| Professional | | $123.86 | $173.01 | $346.02 |