- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $402.31 / $2,651.25 / $6,063.75
| Facility | | $402.31 | $2,651.25 | $6,063.75 |
- 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 / $901.20
| Facility | | $402.32 | $402.32 | $901.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,666.22 / $1,666.22 / $1,666.22
| Professional | | $1,666.22 | $1,666.22 | $1,666.22 |