- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $402.32 / $1,995.84 / $8,705.66
| Facility | | $402.32 | $1,995.84 | $8,705.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.32 / $402.32 / $402.32
| Professional | | $402.32 | $402.32 | $402.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.93 / $1,054.93 / $1,054.93
| Professional | | $1,054.93 | $1,054.93 | $1,054.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $402.32 / $402.32 / $482.78
| Facility | | $402.32 | $402.32 | $482.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.32 / $402.32 / $1,666.22
| Professional | | $402.32 | $402.32 | $1,666.22 |