- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.18 / $229.16 / $6,907.00
| Facility | | $137.18 | $229.16 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.38 / $74.90 / $92.24
| Professional | | $53.38 | $74.90 | $92.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.07 / $87.37 / $131.52
| Professional | | $58.07 | $87.37 | $131.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.91 / $4,296.00 / $6,469.25
| Facility | | $630.91 | $4,296.00 | $6,469.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.10 / $104.74 / $205.96
| Professional | | $84.10 | $104.74 | $205.96 |