- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $315.98 / $403.28 / $3,140.00
| Facility | | $315.98 | $403.28 | $3,140.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.37 / $136.31 / $156.91
| Professional | | $116.37 | $136.31 | $156.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.12 / $180.02 / $206.84
| Professional | | $118.12 | $180.02 | $206.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $520.79 / $520.79 / $520.79
| Facility | | $520.79 | $520.79 | $520.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.79 / $176.00 / $485.50
| Professional | | $123.79 | $176.00 | $485.50 |