- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.31 / $167.06 / $868.00
| Facility | | $142.31 | $167.06 | $868.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.75 / $125.50 / $128.99
| Professional | | $106.75 | $125.50 | $128.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,783.89 / $4,783.89 / $4,783.89
| Facility | | $4,783.89 | $4,783.89 | $4,783.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.20 / $224.27 / $575.51
| Professional | | $101.20 | $224.27 | $575.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.59 / $272.23 / $611.14
| Professional | | $117.59 | $272.23 | $611.14 |