- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.10 / $93.10 / $9,713.04
| Facility | | $93.10 | $93.10 | $9,713.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.85 / $76.34 / $93.11
| Professional | | $52.85 | $76.34 | $93.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.54 / $105.02 / $122.17
| Professional | | $73.54 | $105.02 | $122.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.18 / $100.87 / $154.74
| Professional | | $87.18 | $100.87 | $154.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,713.04 / $9,713.04 / $9,713.04
| Facility | | $9,713.04 | $9,713.04 | $9,713.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.85 / $76.34 / $93.11
| Professional | | $52.85 | $76.34 | $93.11 |