- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.26 / $1,288.25 / $8,709.64
| Facility | | $60.26 | $1,288.25 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $131.83 / $223.87
| Professional | | $60.26 | $131.83 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $100.00 / $165.96
| Professional | | $64.57 | $100.00 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $1,548.82 / $5,370.32
| Facility | | $346.74 | $1,548.82 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Facility | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $97.72 / $154.88
| Professional | | $66.07 | $97.72 | $154.88 |