- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.52 / $6,907.00 / $8,402.64
| Facility | | $174.52 | $6,907.00 | $8,402.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.43 / $117.34 / $126.56
| Professional | | $66.43 | $117.34 | $126.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.20 / $106.89 / $167.43
| Professional | | $67.20 | $106.89 | $167.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,113.20 / $5,113.20 / $5,113.20
| Facility | | $5,113.20 | $5,113.20 | $5,113.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.96 / $123.96 / $123.96
| Professional | | $123.96 | $123.96 | $123.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.68 / $131.91 / $281.54
| Professional | | $89.68 | $131.91 | $281.54 |