- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.75 / $438.13 / $6,178.80
| Facility | | $363.75 | $438.13 | $6,178.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.54 / $170.48 / $175.89
| Professional | | $141.54 | $170.48 | $175.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.16 / $188.52 / $251.46
| Professional | | $134.16 | $188.52 | $251.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,132.00 / $6,132.00 / $6,132.00
| Facility | | $6,132.00 | $6,132.00 | $6,132.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.76 / $189.11 / $380.27
| Professional | | $145.76 | $189.11 | $380.27 |