- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.46 / $2,223.96 / $6,060.96
| Facility | | $113.46 | $2,223.96 | $6,060.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.72 / $96.15 / $113.46
| Professional | | $82.72 | $96.15 | $113.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.41 / $133.03 / $153.31
| Professional | | $95.41 | $133.03 | $153.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $507.71 / $8,767.60 / $12,493.00
| Facility | | $507.71 | $8,767.60 | $12,493.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.68 / $124.58 / $237.17
| Professional | | $93.68 | $124.58 | $237.17 |