- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $187.53 / $187.53 / $6,907.00
| Facility | | $187.53 | $187.53 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.27 / $40.58 / $40.58
| Professional | | $39.27 | $40.58 | $40.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.51 / $51.56 / $67.59
| Professional | | $42.51 | $51.56 | $67.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.08 / $212.08 / $212.08
| Facility | | $212.08 | $212.08 | $212.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.69 / $53.81 / $124.95
| Professional | | $38.69 | $53.81 | $124.95 |